Registered Nurse (RN) Utilization Management - M-F (8a-4:30p) - North Fulton

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Work Shift: Day (United States of America)

About the Role

The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, on any of the 7 days per week, utilizing Indicia for Case Management. The role involves performing clinical reviews through document review, discussion with physicians, and collaboration with the care team to coordinate safe transitions of care for a defined patient population.

The UM Nurse performs utilization review daily by evaluating all new admissions, observation cases, and concurrent reviews. They are assigned to specific units, payers, or patient classes. Clinical reviews are conducted using mcg Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF) criteria, in conjunction with medical records and communication with physicians and physician advisors.

The UM Nurse gathers clinical information, applies appropriate clinical criteria/guidelines, and completes determinations/recommendations for the most appropriate level of care. They share pertinent clinical information with payers and facilitate care/treatment along the continuum of care. The role includes identifying opportunities to ensure effectiveness of healthcare services in the most appropriate setting and timely discharge to the most suitable post-discharge care level.

The UM Nurse obtains timely authorization for all average length of stay (ALOS) days from payers and ensures accurate documentation in EPIC to enable timely billing. They monitor post-discharge, prebill accounts for missing authorizations, ALOS versus authorized days variances, and other discrepancies that may result in denials. The UM Nurse communicates with third-party payors to resolve discrepancies prior to billing, documents all communications and actions, and escalates medical review requests or denial activities as needed.

Responsibilities

• Initiates assessment for necessity and appropriateness of health services by applying established screening criteria (e.g., MCG).
• Ensures timely identification of need and referral for alternative levels of care.
• Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
• Provides required information to payors in a timely fashion and obtains appropriate authorization for all days; ensures authorizations are documented in EPIC.
• Monitors and evaluates patient/client ongoing plans of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care with documentation.
• Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physicians, physician advisors, and managed care representatives to overturn denials.
• Monitors compliance with Medicare/Medicaid regulations.
• Advocates for patients and negotiates or refers for services that may be required outside of patients' healthcare coverage.
• Identifies, participates in, and supports continuous performance improvement initiatives based on identified opportunities.
• Ensures appropriate compliance with payer regulations and well-documented information to prevent payer disputes and denials.
• Assesses insurance and coverage requirements for all payers and ensures adherence to those requirements.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physicians/physician advisors for resolution.
• Completes chart notes accurately and on time per departmental protocol; ensures all records are up-to-date.
• Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor, including authorized days and denied days with reasons for denial.
• Works post-discharge/prebill accounts efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS versus authorized days, or other discrepancies.
• Evaluates clinical documentation in patient records and escalates issues through the established chain of command.
• Tracks avoidable days accurately in the avoidable day module in EPIC per department standard work and performs accurate and timely documentation of all review activities.
• Completes all initial and ongoing professional competency assessments, required mandatory education, and population-specific education.
• Serves as a preceptor and/or mentor for other professionals and/or students.
• Performs other duties as assigned and complies with all WellStar Health System policies, standards of work, and code of conduct.

Requirements

• Associate's degree in Nursing or Diploma in Nursing (required).
• Bachelor's degree in Nursing (preferred).
• Minimum 3 years of strong clinical knowledge with clinical practice/experience.
• Knowledge of Case Management process.

Skills

• Excellent verbal and written communication skills.
• Strong organizational skills.
• Ability to build strong and trusting relationships with physicians and the multidisciplinary team.
• Knowledgeable in utilizing screening criteria for reviewing clinical data and identifying variances.
• Ability to critically think, analyze information, effect change, and impact timely throughput.
• Strong computer skills.