Registered Nurse (RN) - Utilization Review

Location: Rock Hill, SC, Remote

Employment Type: Case Management

Overview

Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, youll have the opportunity to make a meaningful impact in patients lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters!

At Piedmont Medical Network - Rock Hill Hospital, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Job Summary

Up to $20,000 Sign-on Bonus Based on Eligibility

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis.

Responsibilities

 

• Coordinates clinical care and resource utilization by evaluating medical necessity, appropriateness of care, continued stay, and discharge planning in accordance with evidence-based practices and regulatory requirements.
• Completes and submits admission and concurrent reviews to payers, securing authorizations and identifying/documenting avoidable days to improve clinical and financial outcomes.
• Ensures timely communication and documentation of clinical information to payers to support admissions, level of care, length of stay, and authorization requirements.
• Advocates for patients and the organization with payers to obtain appropriate reimbursement, prevent denials, and manage dispute resolution processes, including secondary reviews and peer-to-peer appeals.
• Provides education and guidance to physicians and the healthcare team regarding care progression, appropriate level of care, safe patient transitions, and available patient resources and benefits.
• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services.

Qualifications

• Required:
  • Education: Associates in Nursing required
  • Experience: At least two years acute hospital or Behavioral Health patient care experience.
  • Licensure/Certification: Required qualifications include an active Registered Nurse license

 

• Preferred:
  • Education: BSN 
  • Licensure/Certification: Accredited Case Manager (ACM) preferred

Organization Description

Piedmont Medical Network has served the community of York County and beyond for more than 30 years. Piedmont Medical Network - Rock Hill Hospital is a 288-bed facility that has advanced equipment and experienced healthcare staff catering to the diverse needs of the community it serves. Services include preventive care, advanced heart and stroke care, maternity care and a Level III NICU. Piedmont Medical Network - Fort Mill Hospital opened in 2022 with 100-beds, advanced technology and a compassionate care team. The new hospital features a 24/7 Emergency Department, Intensive Care Unit, Medical/Surgical Unit, and a wide array of Surgical Services and Womens Services.

Piedmont Medical Network has been recognized for its elite level of safety by being awarded the Leapfrog Groups Hospital Safety Score and the Certified Zero Harm Award by SCHA (South Carolina Hospital Association) in collaboration with South Carolinas DHEC. The Cardiac Care program at PMC provides quality care and was designated as a Blue Distinction Center for Cardiac Care by BlueCross BlueShield and a Nationally Certified Cardiac Rehabilitation Program by the American Association of Cardiovascular and Pulmonary Rehabilitation. At Piedmont Medical Network, you can grow your career skills and be a vital member of our team dedicated to improving the health of the community. Join our team!

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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