• All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference.

• Partners with the attending providers throughout hospitalization to promote effective and efficient utilization of clinical resources, ensuring quality, cost effective care. Anticipate next steps and facilitate communication to maximize care efficiencies for the patient and family.

• Identifies social determinants of health that increase the patient's risk for negative outcomes. Ensures clear documentation for the interdisciplinary care team and coordinates post-acute plans with the ambulatory care management team as appropriate. Facilitates patient access to resources and relevant services.

• Addresses and resolves system problems impeding diagnostic or treatment progress. Proactively identifies, resolves and documents delays and obstacles on the patient's behalf. Drives change by identifying areas where performance improvement is needed.

• Navigates value-based care with expertise and ensures longitudinal plan is patient focused and aligns with patient and caregiver goals.

• On the basis of preliminary risk screening, assesses patients' and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.

• 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 an acute care setting. Maintains care management knowledge to provide services in accordance with standards of practice as established by department and management.

• Ensures medical necessity, appropriate level of care and timely implementation of plan of care in accordance with hospital(s) Utilization Review Plan.

• Navigates the team through complex compliance, regulatory and insurance requirements. Coordinates with third party payors on a regular basis.

• 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.

• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

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Minimum Qualifications

• Education - Bachelor's degree in Nursing

• Experience - Three (3) years acute care nursing experience. One (1) year acute care case management experience preferred.

In Lieu Of

• In lieu of the BSN requirement above, a nursing diploma or an Associate degree in Nursing may be considered if the applicant signs a BSN Memorandum of Understanding (MOU) agreeing to enroll in an accredited BSN or MSN program within one year and obtain a BSN or MSN degree within (4) four years of hire date. Further, employees must demonstrate sufficient progress annually toward obtaining an accredited BSN or MSN degree to remain eligible for employment or may be terminated.

• Employees in this title prior to 10/24/2021 are grandfathered into the title and are only required to have an AD N or Nursing Diploma.

Required Certifications, Registrations, Licenses

• Licensed to practice as a Registered Nurse in South Carolina

• Accredited Case Manager (ACM) or Certified Case Manager (CCM) is preferred.

Knowledge, Skills and Abilities

• Knowledge of Medical Necessity Criteria is preferred.