UM Nurse RN-Onsite

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

As an on-site Hospital Utilization Management (UM) Nurse, you are the primary link between the clinical floor and administrative compliance.

Unlike remote roles, this position relies heavily on real-time, face-to-face interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.

• Physician Consultation:
  Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
• Medical Provider Liaison:
  Function as the primary on-site link between the attending/admitting provider and the Physician Advisor for complex medical necessity determinations.

• Interdisciplinary Huddles:
  Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
• ER Throughput Management:
  Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.

• Medical Necessity Reviews:
  Use criteria like Inter Qual or MCG to perform on-site concurrent reviews of active patient care.
• Issuing Official Notices:
  Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Denial Prevention:
  Proactively identify "avoidable days" hospital days that do not meet clinical criteria and escape them to the management team to minimize financial loss.

• Monitors and evaluates patient/clients ongoing plan of care and conducts timely initial and concurrent reviews based on set standards, utilizing screening criteria to monitor care progression with documentation.
• Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials.
• Monitors for compliance of Medicare/Medicaid regulations
• Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
• Function as the primary on-site link between the attending/admitting provider and the physician advisor for complex medical necessity determinations.
• Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
• Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.
• Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities.
• Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and denials.

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG)
• Assesses insurance and coverage requirements for all payers and ensure adherence to those requirements at all time.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor 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 reason for denial.
• Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs authorized days or other discrepancies.
• Evaluates clinical documentation in patient records and escalates issues through the established chain of command.
• Proactively identify "avoidable…