Registered Nurse (RN) - Utilization Management, PRN, Days

Prisma Health•Columbia, SC

1d•Onsite

About The Position

Inspire health. Serve with compassion. Be the difference. This role screens patients to obtain clinical information and makes timely contacts with insurers to provide clinical information to support physician referrals. In collaboration with physicians, the RN leads the multidisciplinary team, including clinical staff and payors, to ensure efficient delivery of quality, cost-effective care. The position requires maintaining expert-level knowledge of body systems, clinical outcomes, and regulatory requirements related to care management services in an acute care setting. The RN serves as a resource for patients and families regarding their rights and responsibilities, especially when care payment is denied or deemed not medically necessary. This role promotes effective and efficient utilization of clinical resources, ensuring quality, cost-effective care and timely clinical reviews to third-party payors.

Requirements

Bachelor's degree in Nursing
Two (2) years acute care nursing experience.
Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Nice To Haves

One (1) year acute case management or utilization management experience preferred.
Utilization management experience is preferred.
Medical Necessity Criteria (Interqual, MCG) knowledge preferred.

Responsibilities

Uses established clinical guidelines for initial/admission and continued stay reviews for patients within assigned unit to ensure medical necessity, appropriate level of care and timely implementation of plan of care in accordance with hospital(s) Utilization Review Plan and CMS regulation.
Maintains expert level knowledge of body systems and expected clinical outcomes for patient disease process.
Maintains current knowledge of changes in state and federal regulatory requirements related to the provision of care management services in the acute care setting.
Serves as a resource for patients and families with regard to their rights and responsibilities, when payment of care is denied or when care is no longer medically necessary.
Consults with interdisciplinary team, Physician Advisor and administrative leadership as necessary to resolve barriers regarding progression of care.
Collaborates with physicians throughout hospitalization, develops an effective working relationship, and provides expertise regarding payor and regulatory guidelines.
Promotes effective and efficient utilization of clinical resources, ensuring quality, cost effective care.
Provides timely clinical reviews to third party payors.
Responds to requests for additional information within 24 hours or next business day.
Partners with RN Hospital Care Managers and SW Hospital Care Managers to resolve payer related barriers.
Maintains care management knowledge to provide services in accordance with standards of practice as established by department and management.
Performs other duties as assigned.