Registered Nurse (RN) - Utilization Management, PRN, Days

Registered Nurse Utilization Management (PRN, Day shift) screens patients to obtain clinical information and coordinates with insurers to provide clinical data for physician referrals. Collaborates with physicians, the multidisciplinary team, and payors to ensure efficient, cost-effective care. Applies clinical guidelines for initial/admission and continued stay reviews to determine medical necessity and appropriate level of care per CMS regulations. Maintains knowledge of body systems and regulatory changes related to care management in acute settings; serves as a resource for patients and families regarding rights and responsibilities when payment is denied or care is no longer medically necessary. Supports timely information delivery to third-party payors (within 24 hours/next business day) and partners with RN Hospital Care Managers and Social Work to resolve payer-related barriers. Works within Interqual and MCG criteria and aligns with department standards for high-quality, efficient utilization management. This non-management role reports to a supervisor, manager, director, or executive, located at Prisma Health’s Corporate - Columbia facility in South Carolina.