Inspire health. Serve with compassion. Be the difference.
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 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. Includes, but not limited to, delivery of the regulatory documents as provided by CMS.
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.
Supervisory/Management Responsibility
This is a non-management job that will report to a supervisor, manager, director, or executive.
Minimum Requirements
Education - Associate's degree in Nursing. BSN preferred.
Experience - Two (2) years acute care nursing experience. One (1) year acute case management or utilization management experience preferred. Utilization management experience is preferred.
In Lieu Of
Employees in this title prior to 1/26/2025 are grandfathered into the title and are only required to have an AD N or Nursing Diploma.
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 the team member is working.
Knowledge, Skills and Abilities
Medical Necessity Criteria (Interqual, MCG) knowledge preferred.
Work Shift
Day (United States of America)Location
Blount Memorial HospitalFacility
8001 Blount Memorial Hospital, Inc.Department
BMH Hospital Care ManagementShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.