Registered Nurse (RN) - Utilization Management [Blount],Care Management, Full-Time, Days

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

Hospital

Facility

8001

Blount Memorial Hospital,

Inc.

Department

80017517

BMH Hospital Care Management

Share 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.