At WellStar we all share common goals. That's what makes us so successful and such an integral part of our communities.
We want the same things, for our organization, for our patients, and for our colleagues. As the most integrated healthcare provider in Georgia, this means we pride ourselves on investing in the communities that we serve. We continue to provide innovative care models, focused on improving quality and access to healthcare.
The Utilization Management Nurse (UM) Coordinator is responsible for conducting medical necessity reviews utilizing Millman Care Guidelines, clinical reviews with payers and collaborating 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 units/and or payer/and or patient class. All clinical reviews will be done by utilizing Milliman criteria in conjunction with medical records documentation communication with physicians and physician's advisors.
The UM nurse will gather clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and clinical review to the payers. Along the continuum of care, communicates with providers and other parties to facilitate care/treatment. Identifies members for referral/consult opportunities to streamline care and throughput ensuring delays are avoided. identifies opportunities to ensure effectiveness of healthcare services in the most appropriate
setting always as well as timely discharge to the most appropriate level of post discharge care.
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 needed.
UM Nurse will work 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.
Tracks avoidable days accurately in the avoidable day module in EPIC. Perform accurate and timely documentation of all review activities
Required Minimum Education: RN with a Georgia License, Graduate of an accredited/approved school of nursing:
Baccalaureate degree in nursing (BSN) from an accredited school of nursing preferred.
Required Minimum Experience: Strong clinical knowledge with three to five years clinical practice/experience is
Wellstar Health System, Inc.