Registered Nurse - Utilization Review - Acute Care Part-Time Weekends
<strong>Role Overview:</strong> The Utilization Management (UM) Nurse conducts medical necessity reviews, collaborates with healthcare providers, and ensures appropriate care transitions. Responsibilities include reviewing new admissions, observation cases, and concurrent care using clinical criteria (e.g., MCG, Indicia), documenting findings, and obtaining payer authorizations. The UM Nurse evaluates clinical documentation, monitors discharge plans, and resolves billing discrepancies to prevent denials. They communicate with payers and care teams to facilitate timely approvals and optimal patient care.<br><br><strong>Key Duties<br><br></strong><ul><li>Perform clinical reviews and assessments based on established criteria.</li><li>Secure timely authorizations for hospital stays and services.</li><li>Monitor ongoing care and evaluate the appropriateness of admissions and denials.</li><li>Document all review activities accurately in electronic health records.</li><li>Collaborate with physicians, payers, and multidisciplinary teams to resolve discrepancies.</li><li>Ensure compliance with healthcare regulations and payer requirements.</li><li>Participate in performance improvement initiatives and mentor colleagues.<br><br></li></ul><strong>Qualifications & Skills<br><br></strong><ul><li>Minimum 3 years of clinical practice or experience; nursing degree (Associate, Diploma, or Bachelor preferred).</li><li>Active RN license (Single State or Multi-state Compact).</li><li>Strong knowledge of case management processes, clinical judgment, and documentation.</li><li>Excellent communication, organizational, and computer skills.</li><li>Ability to build trusting relationships with providers and teams.<br><br></li></ul>This role is part-time on weekends at Cobb hospital, focusing on clinical evaluation, documentation, and payer communication to support safe, efficient patient care and billing processes.
