Utilization Management RN – Care Coordination Specialist

Wellstar Health Systems; Roswell (GA); On-site; USD 85,000 - 110,000; Full time

Job summary

Wellstar Health System is seeking an Utilization Management Nurse (UM) Coordinator to conduct medical necessity reviews 24/7. The role uses MCG criteria to determine level of care, communicates approvals to payers and care teams, and ensures timely authorization and accurate documentation in EPIC.

Responsibilities include post-discharge/prebill review, variance tracking, and collaboration with physicians and payer representatives to optimize care and minimize denials.

Qualifications

• Knowledge of established screening criteria (e.g., MCG).
• Ability to assess necessity and appropriateness of health services.
• Experience communicating with payers and clinicians.

Responsibilities

• Initiates assessment for necessity and appropriateness of health services using MCG criteria.
• Assesses insurance and coverage requirements for all payers and ensures adherence.
• Identifies issues related to patient type and admission appropriateness; collaborates with physicians.

Skills

MCG criteria knowledge

Medical necessity assessment

Communication with payers

Tools

EPIC system

Job description

Wellstar Health System is seeking an Utilization Management Nurse (UM) Coordinator to conduct medical necessity reviews 24/7. The role uses MCG criteria to determine level of care, communicates approvals to payers and care teams, and ensures timely authorization and accurate documentation in EPIC.

Responsibilities include post-discharge/prebill review, variance tracking, and collaboration with physicians and payer representatives to optimize care and minimize denials.