Functions under the direction of the Utilization Documentation Manager and Director of Case Management. Demonstrates fiscal
responsibility related to patient needs, resource utilization, payer requirements and organizational goals; also acts as a model of
outcomes for quality, value and efficiency. Screens medical records for admission and concurrent criteria (medical necessity/level
of care) utilizing InterQual® criteria/ 3M endcoder and documenting the review in the Case Management software system and/or
hospital EMR. Secures authorization/certification for services by communicating necessary and requested information with payors.
Communicates information that will impact the discharge plan to the Transitional Care Coordinator to ensure high quality care
coordination. Maintains an awareness of the business of medicine and transitional healthcare changes, including but not limited to
value-based purchasing, bundled payments, accountable care organizations and the readmission reduction program.

Special Qualifications
Required: Graduate of an accredited school of nursing; Licensed to practice as a Registered Nurse in South Carolina;
Three years of hospital clinical nursing experience in designated practice area. CPR within 1 month of employment.
Preferred: BSN or Baccalaureate degree in health-related field; Two years experience as Utilization Reviewer/Care
Coordinator or Clinical Documentation Specialist with knowledge of third party reimbursement requirements; Practice
experience in Critical Care, Emergency Care or Surgical Care. National certification.