Registered Nurse (Rn) - Utilization Management, Prn

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Job Summary

Screens patients to obtain clinical information and make timely contacts with insurers to provide clinical information to support physician referrals. In collaboration with physicians, leads the multidisciplinary team including clinical staff and payors to ensure efficient delivery of quality, cost-effective care.

Accountabilities

• 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. 15%
• 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. 20%
• 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. Includes, but not limited to, delivery of the regulatory documents as provided by CMS. 15%
• 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. 15%
• 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. 15%
• 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. 20%

Supervisory/Management Responsibility

This is a non-management job that will report to a supervisor, manager, director, or executive.

Minimum Requirements

• Bachelor's Degree in Nursing
• Two (2) years acute care nursing experience. One (1) year acute case management or utilization management experience preferred.

Required Certifications/Registrations/Licenses

• Currently licensed or eligible to be licensed as a Registered Nurse (RN) by the South Carolina Board of Nursing.

Other Required Skills and Experience

• Utilization management experience is preferred.
• Medical Necessity Criteria (Interqual, MCG) knowledge and experience is preferred.

Grandfather Status

Employees in this title prior to 10/24/2021 are grandfathered into the title and are only required to have an AD N or Nursing Diploma.

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70017535 Utilization Management

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