Insurance Case Manager Jobs in Winder, GA (NOW HIRING)

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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

The ED Admissions Case Manager is responsible for evaluating and screening all ED admissions using screening guidelines to ensure patients are in the appropriate status and level of care based on the physician's documentation. The ED Admissions Case Manager collaborates with Physicians, patient and families, and other members of the healthcare team to ensure an appropriate plan of care and the appropriateness of services provided. The ED Admissions Case Manager provides comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Additionally, the ED Admissions Case Manager coordinates a team approach designed to facilitate the achievement of expected patient outcomes with appropriate transitions to the next level of care and also provides cross coverage for other ED RN Case Managers as required.

• Licensure or other certifications: Professional RN licensure, Active GA licensure,

• Educational Requirements: Associate degree. Graduate of an accredited school of nursing.

• Minimum Experience: One (1) to two (2) years of experience in Utilization Management applying screening guidelines (InterQual or MCG Guidelines) or other related Case Management experience (i.e. Acute Care, Insurance Case Management, Workers Compensation). Three (3) to five (5) years of experience in direct patient care and/or case management.

• Other:

• Preferred Licensure or other certifications: Case Mgmt. Certification (CCM or ACM) preferred.

• Preferred Educational Requirements: Bachelors Degree

• Preferred Experience: Acute Care UR/CM experience preferred.

• Other:

• Demonstrated aptitude, clinical knowledge, and critical thinking skills in a fast-paced ED environment.

• Working knowledge of State and Federal regulations third party/governmental payer regulatory requirements, and in and out of network coverage benefits.

• Must demonstrate excellent observation skills, analytical thinking, problem solving abilities, and excellent written and verbal communication.

• Proficiency with computers and software.

• Knowledgeable of financial/reimbursement criteria as it relates to all payors.

• Demonstrated interpersonal skills, including professionalism, being a team player, and a positive approach to situations. The position requires the ability to be self-directed.

• Determines if patients meet nationally recognized medical necessity criteria for admission/transfer into the system by performing admission by utilizing screening guidelines (InterQual/MCG) based on Physician documentation to ensure the patient is in the right Patient Class, and Level of Care

• Coordinates appropriate patient entry into NGMC's acute beds, utilizing clinical criteria to assess medical appropriateness and patient status. Communicates directly with physicians and referring facilities to ensure collaborative practice.

• Refers appropriate cases to physician advisors for review and status determination. Communicates with physician to obtain appropriate status order based on determination.

• Work collaboratively with the Physician, nursing staff, and care team to ensure patients are meeting the expected length of stay and to assure a timely discharge and appropriate transition to the next level of care.

• Communicate and coordinate with care team consistently to ensure patients are in the right status and level of care. Actively supports a customer service oriented environment to continually enhance customer satisfaction.

• Adheres to all regulatory and DNV requirements; Knowledgeable of third party payers (PPO/HMO's) to facilitate appropriate outcomes and ensure coverage of services rendered.

• Physician education and feedback to include guidance for status determinations and supporting documentation for medical necessity

• Maintains confidentiality and respects patients privacy. Performs in a manner that respects HIPPA laws.

• Contributes to the productive and effective operation of the Care Coordination area. Identifies and escalates opportunities for process improvement up the chain of command.

• Provides coordination and facilitation oversight of patient care to assure required interventions occur in proper sequence and processes occur in a timely manner without delays. Identifies and acts upon potential delays in services; escalates unresolved delays to management for appropriate intervention.

• Assess, coordinate and facilitate patient's discharge plan to assure post-acute needs are arranged and secured prior to discharge when applicable; Communicate discharge plan with Physician, patient/family, and other members of the healthcare team as appropriate; Reassess discharge plan routinely throughout patient's stay to ensure timely, safe discharge and appropriate transition to the next level of care. Provides patient/family with information regarding their plan of care, discharge and any financial responsibility of inpatient or post-hospitalization services.

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.