Utilization Management Jobs in Griffin, GA (NOW HIRING)

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

Ideal candidates will possess the following:

• Prior Medical Care Coordination experience in an Acute Care setting.

The Care Coordinator is responsible for coordination of care across the continuum during the patient's acute, chronic and long-term stages of illness for a defined patient population. This includes utilization management, transitional care planning, psychosocial and functional status assessment, patient advocacy, education for the patient/family, and monitoring quality indicators to demonstrate outcomes resulting from the service provided. Collaborates with all team members to provide a comprehensive assessment of the patient's plan of care, goal/outcome attainment and continued care needs.
It is expected that all RN Clinical Nurses are licensed, knowledgeable and uphold the practice of nursing as outlined by the Georgia Professional Nurse Practice Act and implements the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association. As a member of the patient services team, it is expected that the individual upholds the voice of the patient, System policies and procedures while supporting service excellence goals and providing and unwavering focus on exceeding the expectations of our patients and consumers.

Disposition Planning
Implements Discharge planning and provides resource information in a timely and efficient manner.
Identifies and documents barriers for timely disposition
Collaborates with other members of the health care team in planning care appropriate for age
Provides education/counseling to patient/family in understanding, accepting and following medical recommendations of his/her conditions
Provides assistance with Advance Directives for customers throughout WellStar Health System.
Understands eligibility processes and criteria for both private and public local, state and federal resources
Responds to referrals from hospital staff, physician offices, community and family to provide resource information, counseling and education to the community
Provides financial needs assessment for patients in need of assistance for follow-up care throughout the continuum
Provides follow-up for patients needing post-discharge assistance
Allows for any cultural or religious beliefs in providing service and continuity of care
Always partners with the patient and significant others (as appropriate) using such appropriate method for setting and purpose (e.g., interdisciplinary rounds, keeping the patient and significant others updated and making the patients goals the focus of the plan of care.) * Exemplary Practice and Outcomes
Participates in the development of protocols and procedures when called upon or through self-initiation in collaboration with care managers and other members of the health care team to achieve best practice outcomes (i.e. decrease in re-admission rates, avoidable days, adverse events, etc.)
Resources and Support
Utilization Management
Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. Interqual)
Timely identification and referral for alternative level of care
Responsible for timely and accurate certification of hospital admission
Provides required information to payors
Monitors and evaluates patient/clients ongoing plan of care and facilitates modification utilizing established screening criteria to determine level of care with documentation in the computerized Utilization Management module
Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician and managed care representative and Medical Director or VP Medical Affairs
Monitors for compliance of Medicare/Medicaid regulations (e.g. order for patient type for billing, appropriate billing)
Negotiates and refers for services outside of patients health care plan
Evaluates and negotiates patients needs based on quality, cost and necessity
Participates and supports performance improvement inclusive of all stakeholders, research and research utilization to promote safe, quality patient care including initiating and/or leading such activities as well as, promoting an inter/intra-disciplinary process and actively supports/participates in shared governance at all levels in the system
Teamwork and Collaboration and Evidence Based Practice Research
Assessment
Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. Interqual)
Assesses insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers
Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution
Documentation
Initial psychosocial /functional assessment completed and documented in medical record
Complete chart notes accurately and timely per Departmental protocol
Ensure all records are up-to-date and legible.
Complete all Electronic Medical Record software screens
Ensure timely and accurate documentation of clinical reviews and insurance updates as required by payor
Accounts for and indicates all services delivered in Electronic Medical Record
Participates in data collection, poses relevant clinical questions to advanced evidence-based practice. Consults appropriate experts and uses appropriate resources and evidence to address practice questions
Evidence Based Practice and Research
Professional Development and Initiative
Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education
Serves as a preceptor and/or or mentor for other professional and/or students, to ensure that there is a current and future qualified workforce
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

• Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

All certifications are required upon hire unless otherwise stated.

• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact or LCSW - Lic Clinical Social Worker GA or LMSW - Lic Master Social Worker GA or MSW - Master Social Worker

Minimum 3 years Three to Five years Clinical Practice/Experience Preferred

Knowledge of Case Management process.
Excellent organizational and professional communication skills.<