RN Care Management(Remote)

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.
Work Shift
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.
The on-site UM Nurse is a Registered Nurse (RN) responsible for performing admission and concurrent medical record reviews to ensure patients are in the correct Patient Class (e.g., By being physically present, one is able to directly influence the hospital's throughput, length of stay, and reimbursement accuracy.
Key On-Site Responsibilities
Physician and Clinical Collaboration
o 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.
o Medical Provider Liaison: 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.
o 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.
Administrative & Financial Compliance
o Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
o Denial Prevention: Proactively identify "avoidable days "hospital days that do not meet clinical criteria and escalate them to the management team to minimize financial loss.

Utilization Management

• 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.
• 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. Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.
Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. Evaluates clinical documentation in patient records and escalates issues through the established chain of command.
* Proactively identify "avoidable days" hospital days that do not meet clinical criteria and escalate them to the management team to minimize financial loss.
Serves as a preceptor and/or or mentor for other professional and/or students
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

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

RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
Knowledge of Case Management process.
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. Strong computer skills required. Connect with the most integrated health system in Georgia, and start a future that gives you more.