Registered Nurse (RN) - Utilization Management, PRN, Days
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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.
Essential Functions
All team members are expected to be knowledgeable and compliant with Prisma Health’s values: Inspire health. Serve with compassion. Be the difference.
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 and remains current on state and federal regulatory requirements related to care management services in the acute care setting.
Serves as a resource for patients and families regarding their rights and responsibilities when payment of care is denied or care is no longer medically necessary, including delivery of regulatory documents as required by CMS.
Consults with interdisciplinary team, Physician Advisor and administrative leadership to resolve barriers regarding progression of care. Collaborates with physicians throughout hospitalization, develops effective working relationships, 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 and 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 department and management standards of practice.
Performs other duties as assigned.
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. Utilization management experience is preferred.
Required Certifications, Registrations, Licenses
Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state where the team member works.
Knowledge, Skills and Abilities
Medical Necessity Criteria (Interqual, MCG) knowledge preferred.