[Hiring] Case Manager/ Utilization Review Registered Nurse @Trinity Health

Role Description

The Utilization Review (UR) Coordinator collaborates with a multidisciplinary team to ensure patients receive the appropriate level of care throughout the continuum of care in an efficient, cost-effective, and quality-focused manner.

• Conducts clinical reviews using established medical necessity criteria to support accurate patient status determinations.
• Serves as a liaison between the hospital and external payers regarding medical necessity, severity of illness, intensity of service, authorization requirements, and timely utilization of hospital services.
• Evaluates patient status using approved medical necessity criteria (MCG and InterQual).
• Monitors patient progression across the continuum of care.
• Collaborates with attending physicians, Physician Advisors, and administrative leadership to determine appropriate patient status.
• Completes and submits all initial, concurrent, and discharge reviews within established timeframes.
• Facilitates peer-to-peer reviews and escalation processes with payers and Physician Advisors.
• Maintains knowledge of Medicare, Medicaid, commercial payer requirements, and applicable regulations.
• Effectively organizes, prioritizes, and manages daily assignment caseloads within EPIC Account.
• Meets established productivity, quality, timeliness, and documentation standards.
• Responds to payer review requests in accordance with contractual and regulatory requirements.
• Obtains and manages payer authorizations and notifications.
• Assists with utilization management reporting, data collection, and performance improvement initiatives.
• Demonstrates service excellence by providing complete clinical information to review organizations following HIPAA guidelines.
• Identifies, reviews, and documents Medicare 1 Day stays and Condition Code 44 (CC44) cases.
• Collaborates with onsite staff to ensure timely delivery of required regulatory notices and documentation.
• Serves as a resource for utilization management standards and medical necessity guidelines.
• Participates in denial prevention, denial management, auditing activities, and performance improvement initiatives.
• Actively manages and resolves concurrent payer denials.
• Accurately documents all pertinent communications in the hospital's EPIC Electronic Medical Record (EMR) system.
• Participates in related committees as assigned.
• Maintains good rapport and cooperative relationships both internally and externally.
• Addresses conflict professionally and constructively.
• Identifies opportunities for improvement and participates in implementation efforts.
• Maintains professional competency through ongoing education and self-directed learning.
• Maintains a working knowledge of applicable Federal, State and local laws and regulations.
• Safeguards Protected Health Information (PHI) by adhering to the "minimum necessary" standard.
• Assumes responsibility for performance of job duties in the safest possible manner.
• Behaves in accordance with the Mission, Vision, and Values of St. Mary’s Health System.
• Attends team huddles and meetings when working; if unable to attend, review of notes/minutes is required.

Qualifications

• Current GA RN license; BLS required.
• Must be a graduate of an accredited school of nursing; BSN recommended.
• Three to five years related experience and clinically relevant knowledge.

Requirements

• Clinical and analytical skills necessary to facilitate collection of patient clinical information.
• Proficiency in MCG and INTERQUAL Criteria applications.
• Strong organization and prioritization skills.
• Strong interpersonal and communication skills, including telephonic and electronic.
• Ability to concentrate and pay close attention to detail.
• Basic keyboarding skills required; preferred skills include EPIC, Microsoft Word, Microsoft Teams, Microsoft Outlook, and Microsoft Excel.

Benefits

• Rooted in our Mission and Core Values, we honor the dignity of every person.
• We are an Equal Opportunity Employer.