[Hiring] RN Central Utilization Mgmt @Wellstar Health System

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Role Description

The Utilization Management Nurse (UM) Coordinator is responsible for conducting medical necessity reviews 24 hours per day, 7 days per week. Utilizing mcg Indicia, clinical reviews are performed and clinical information shared with payers and authorization status shared with the care team on the coordination of safe transitions of care for a defined patient population.

• Perform utilization review every day by looking at all new admissions, all observation cases, and concurrent reviews.
• Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to complete the determination/recommendation for the most appropriate level of care status.
• Communicate with providers and other parties to facilitate care/treatment.
• Obtain timely authorization of all ALOS days from payers and ensure documentation in EPIC for timely billing.
• Monitor post-discharge, prebill accounts that do not have an authorization on file.
• Communicate with third-party payors to resolve discrepancies prior to billing.
• Document all communications and actions taken on the account in accordance with policies and procedures.
• Work efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS vs. authorized days, or other discrepancies.
• Evaluate clinical documentation in patient records and escalate issues through the established chain of command.
• Track avoidable days accurately in the avoidable day module in EPIC.
• Perform accurate and timely documentation of all review activities.

Qualifications

• Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing - Preferred

Requirements

• Minimum 3 years of strong clinical knowledge with clinical practice/experience.
• All certifications are required upon hire unless otherwise stated.
• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor.
• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact.

Benefits

• Join us and discover the support to do more meaningful work—and enjoy a more rewarding life.
• Connect with the most integrated health system in Georgia, and start a future that gives you more.

Professional Development and Initiative

• Complete all initial and ongoing professional competency assessments, required mandatory education, and population-specific education.
• Serve as a preceptor and/or mentor for other professionals and/or students.