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 24 hours
per day, 7 days per week. utilizing Millman Care Guidelines, l 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
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: Graduate of an accredited/approved school of nursing: Baccalaureate degree in
nursing (BSN) from an accredited school of nursing preferred.
Required Minimum Certification: RN with a Georgia License
Required Minimum Experience: Strong clinical knowledge with three to five years clinical practice/experience is
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.