Case Manager Utilization Review Nurse Jobs in Rincon, GA

Benefits:

· Retirement plan 403 (b) and 457

· Health insurance

· Dental insurance

· Vision insurance

· Prescription Drug Plan

· Hospital Discount

· Flexible spending account

· Paid time off

· Extended Days off (Sick time)

· Employee assistance program

· Strive365 Wellness Program

· Basic Life insurance (Employer Paid)

· Voluntary Life insurance/Accident/Critical Illness

· Disability (LTD and STD)

· Tuition reimbursement

· Legal and ID Shield

· Discounted Gym membership

· Cafeteria Payroll Deduction

· Employee Perks Program

· Student Loan Relief and Assistance

· Employee Rewards and Recognition Program

· Bereavement Leave

JOB SUMMARY

Under the general direction of the Director of Transitional Care, the RN Case Manager is accountable for a designated patient caseload and plans effectively to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services required to meet the patient’s health and human service’s needs. It is characterized by advocacy, communication, and resource management, and promotes quality and cost-effective interventions and outcomes in accordance with The Joint Commission, federal, state and local guidelines.

The position requires a solid knowledge base, critical thinking skills, and ability to apply evidence-base guidelines are crucial in addition to excellent interpersonal skills, self-motivation and strong organizational skills to function in a semi-autonomous role within a fast paced and dynamic environment.

JOB QUALIFICATIONS:

Minimum Level of Education: Must be a graduate of an accredited School of Nursing with Associates degree or bachelor’s degree in nursing.

Formal Training: Management skills with experience in planning, organizing, implementing, facilitating, interviewing, counseling, and verbal and written communications.

Licensure, Certification, Registration: Must have and maintain an unencumbered license/Certification as a Registered Nurse with the State of Georgia or compact license and maintain a BLS CPR certification.

Work Experience: Minimum of two years acute hospital nursing experience required; (2) two years acute hospital Case Management experience preferred. Utilization review experience preferred with MCG or InterQual guidelines; Intermediate computer skills with word processing and spreadsheet capabilities.

STANDARDS OF PERFORMANCE

1. Admission review and continued stay reviews of patients using evidence based clinical based guidelines (Milliman),

2. Contacting insurance companies to provide clinicals to support admissions/continued hospital stays,

3. Referring cases to the Physician Advisor for further review and collecting QA and Avoidable Days data as directed.

4. Function as an integral member of a collaborative and interdisciplinary team, to re-assess and adjust the plan for care progression and transition according to the patient’s clinical condition.

5. Provides federal notices to Medicare beneficiaries per federal guidelines and hospital policy.

6. Supports Nursing Services and other clinical and non-clinical ancillary services in assuring the continuum of care for patients and in maintaining the quality of service delivery.

7. Serve as a patient advocate in appropriate utilization of benefits and community resources

8. Completes and documents timely clinical reviews based on assessment of medical necessity and documented clinical findings in accordance with hospital policy and payer findings.

9. Demonstrates understanding of medical necessity and intensity of service and incorporates payer requirements into development of safe, effective and timely discharge plan.

10. Incorporates risk of re-admission and socio-economic factors in the creation of a safe and individualized into transition plan.

11. Engages patient and family support network in developing the transition plan.

12. Collaborates with interdisciplinary team throughout the patient’s stay to re-assess and adjust the plan for care progression and transition according to the patient’s clinical condition.

13. Maintains communication with Transitional Care Director to review and discuss patient care, progress and identified outcomes.

14. Participates and facilitates patient care conferences and family meetings.

15. Facilitates peer to peer discussions between attending physicians, case managers, physician advisors in cases requiring evaluation and justification of medical necessity for admission by payer.

16. Assures prompt reporting of medical/legal issues to Risk Management, supervisor, and appropriate Administrative parties. .

17. Develop and maintain a good working rapport with other departments within the facility and outside community health & welfare and social agencies to assure that social service programs can be properly utilized to meet the needs of the patients.

18. Within Scope of Nursing practice, the Case Manager continuously assesses self-knowledge and competencies to assure job performance

19. Ensures adherence to proper infection control, OSHA and safety standards.

20. Perform other duties as requested, required, needed or assigned.