RN Central Utilization Mgmt - Remote Eligible

Job Summary

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.

Core Responsibilities and Essential Functions

Utilization Management

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria.
• 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.
• Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards.
• 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.
• 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 mentor for other professional and/or students.

Complies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education

Graduate of an accredited/approved school of nursing Bachelor's Degree in nursing (BSN) from an accredited school of nursing

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

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

Required Minimum Experience:

Minimum 3 years Strong clinical knowledge with clinical practice/experience

Required Minimum Skills:

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

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.