RN Utilization Review FT Days

About Hilton Head Regional Healthcare

Hilton Head Regional Healthcare provides comprehensive healthcare to the Lowcountry at four locations including Coastal Carolina Hospital, Hilton Head Hospital, the Bluffton Medical Campus and the Bluffton-Okatie Outpatient Center. Coastal Carolina Hospital (CCH) is a 41-bed acute care hospital located in Hardeeville, S.C., serving the medical and healthcare needs of Jasper and Beaufort counties since November 2004. Hilton Head Hospital (HHH) is a 109-bed acute care hospital located on Hilton Head Island, S.C. Opened in 1974, HHH serves Hilton Head Island, Bluffton, Okatie and surrounding counties. All facilities are owned and operated by Dallas-based Tenet Healthcare Corp. Both hospitals are accredited by The Joint Commission, the nation's oldest and largest hospital accreditation agency. Learn more about Hilton Head Regional Healthcare at www.hiltonheadregional.com.

About Hilton Head Hospital

Hilton Head Hospital (HHH) is a 109-bed acute care hospital located at 25 Hospital Center Boulevard in Hilton Head Island, SC. Opened in 1974, HHH serves Hilton Head Island, Bluffton, Okatie and surrounding counties through its care team of over 600 colleagues and over 100 physicians. The hospital provides a continuum of services through its centers and programs, including a 24-hour emergency department, critical care, cardiac care ranging from minimally invasive to open heart surgery, obstetrics/gynecology, urology, a nationally accredited breast health center, spine care, gastroenterology, surgical services, cardiac and physical rehabilitation, and a 12-bed geriatric psychiatric inpatient unit. To learn more about Hilton Head Hospital, please visit www.hiltonheadregional.com.

RN Utilization Full Time Days Review Position Days

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. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention

• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient

• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy

• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits

Responsibilities

• Accurate medical necessity screening and submission for Physician Advisor review

• Securing and documenting authorization for services from payers

• Managing concurrent disputes

• Collaborating with payers, physicians, office staff and ancillary departments

• Timely, complete and concise documentation in the Tenet Case Management documentation system

• Maintenance of accurate patient deomgraphic and insurance information

• Identification and documentation of potentially avoidable days

• Identification and reporting over and underutilization

THE RN UTILIZATION REVIEW FULL TIME DAYS CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.

Education

Required: Graduate of an accredited school of nursing.

Preferred: Academic degree in nursing (bachelor's or master's)

Experience

Required: 2 years pf acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.

Certification

Required: RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.

Preferred: Accredited Case Manager (ACM).

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