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Work Shift

Day (United States of America)

Job Summary:

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. The Utilization Management Nurse will perform utilization review every day by looking at all new admissions, all observation cases and concurrent reviews. They will be assigned to specific payer(s)/and or units/and or patient class. All clinical reviews will be performed, utilizing mcg Indicia when specified, in conjunction with medical records documentation communication with physicians and physician's advisors.The UM nurse will 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 and provide supporting clinical information to the payers. Along the continuum of care, communicates with providers and other parties to facilitate care/treatment.Utilization Management Nurse will obtain timely authorization of all ALOS days from payers and ensure this is documented in the appropriate place in EPIC to enable timely billing. Will monitor post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise.The UM Nurse will communicate with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as neededUM Nurse will work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS vs. 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. Perform accurate and timely documentation of all review activities.

Core Responsibilities and Essential Functions:

Utilization Management* Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).* Ensures timely identification of need and referral for alternative level 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 in a timely manner.* Monitors and evaluates patient/clients ongoing plan 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 physician, physician advisors and managed care representative to overturn denials.* Monitors for compliance of Medicare/Medicaid regulations* Advocates for patient and negotiates and refers for services that maybe required outside of patients health care coverage.* 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.Assessment* 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.Documentation and Post Discharge* 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.Professional Development and Initiative* Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.* Serves as a preceptor and/or or mentor for other professional and/or studentsAssessment* Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (mcg Indicia)* 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.Utilization Management* Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (mcg Indicia).* Ensure timely identification and referral for alternative level of care.* Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.* Provides required information to payors on time and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC on time.* Monitors and evaluates patient/clients ongoing plan 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 physician, physician advisors and managed care representative to overturn denials.* Monitors for compliance of Medicare/Medicaid regulations.* Advocates for patient and negotiates and refers for services that maybe required outside of patients health care coverage.* 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.Documentation and Post Discharge* 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 missing authorization numbers, ALOS vs. authorized days or other discrepancies.* Evaluates clinical documentation in patient records and escalates issues through the established chain of command.Professional Development and Initiative* Completes all initial and ongoing professional competency assessments, required mandatory education, and population specific education.* Serves as a preceptor and/or or mentor for other professionals and/or students.Performs other duties as assignedComplies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

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

Required Minimum License(s) and Certification(s):

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

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years "Strong clinical knowledge with clinical practice/experience.Required

Required Minimum Skills:

Knowledge of Case Management process. MediumExcellent verbal and written communication skills. HighStrong organizational skills. HighAbility to build strong and trusting relationships with physicians and the multidisciplinary team. HighKnowledgeable with utilizing screening criteria in review of clinical data and identifying variance. MediumAbility to critically think and analyze information, effect change, and effectively impact timely throughput. HighStrong computer skills required. High

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