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RN Case Manager

Optim Medical Center - Tattnall is seeking a full time RN Case Manager for our Reidsville, GA location.

Job Requirements:

• Maintains medical and orthopedic surgical patients in appropriate level of care.

• Obtains prior authorization from insurance on newly admitted medical patients.

• Makes notification of admission and discharge on Inpatient orthopedic and spine surgery patients.

• Provides medical necessity updates to insurance companies on all admissions requiring additional stay beyond approval.

• Writes appeal letters for denials and reviews with physicians on appropriate level of care based on Milliman Care Guidelines (MCG) criteria.

• Completes DMA6 and Level 1 paperwork for patients being admitted/transferred to Swing bed, Skilled Nursing Facility, or Nursing Home placement.

Qualifications:

1. Possession of a valid state license as a registered nurse

2. Possession of Basic Life Support, ACLS, and PALS certifications

3. Ability to develop policies and procedures

4. Possess creative abilities to develop education tools

5. Excellent written and verbal skills

6. Ability to teach and evaluate clinical performance of staff

7. Ability to teach patients/families and evaluate the response and retention of information

Duties and Responsibilities:

1. Performs admission, concurrent, and focused reviews using criteria as specified by payor and maintains contact with payor as specified until patient's discharge.

2. Maintains computer or paper record of data obtained from admission, concurrent, and focused reviews.

3. Performs or assists in retrospective reviews or studies following designated guidelines established by various clinical disciplines.

4. Consults with admitting physician or physician advisor regarding specific patients as required.

5. Assists Utilization Review Committee in identifying areas of mis-utilization.

6. Prepares for on-site monitoring reviews by Blue Cross, PRO, and various third-party review organizations.

7. Compliments activities of existing internal hospital utilization review and medical audit activities.

8. Reviews charts daily, collects the necessary data and for the review, and prepares documentation for the review.

9. Assumes active role in implementation, monitoring, and evaluation of utilization review.

10. Refers all questionable admissions and possible extensions of length of stay to Utilization Review Committee for reviewing.

11. Gives prompt written and oral notification when the final determination of the committee or subcommittee is that hospitalization is not medically necessary or that further stay is not considered medically necessary, therefore not being payable by the program involved.

12. Notifies the Hospital Administration, attending physician, patient, the patient's next of kin, and the appropriate agency within specified time set forth by the UR Committee.

13. Abides by code of ethical conduct as well as confidentiality guidelines.

14. Performs all other duties as assigned.

Physical and Sensory Requirements:

(With or without the aid of mechanical devices):

1. Must be able to move intermittently throughout the workday

2. Must be able to write and speak the English language in an understandable manner

3. Must be able to cope with the mental and emotional stress of the position

4. Must possess sight/hearing senses or use of prosthesis that will enable these senses to function adequately so that the requirements of the position can be met fully

5. Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies

6. Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination

7. Must be able to push, pull, move, and/or lift a minimum of 50 pounds to a minimum height of 3 feet and be able to push, pull, move and/or carry such weight a minimum distance of 20 feet

8. Must be able to assist in the evacuation of patients during emergency situations

9. Requires full range of body motion, including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Frequent standing and walking or other means of mobility for extended periods of time.

10. Requires normal visual acuity and hearing.

Working Conditions:

May be exposed to blood, body fluids, infectious diseases, air contaminants (including tobacco smoke), and hazardous chemicals. May be exposed to the hepatitis B virus.

Training:

Minimum of eight (8) hours of orthopedic specific training required annually.

Optim Offers:

• Competitive Pay
• Company Benefits
• Vacation, Personal Time Off, and Sick Leave
• Holiday Pay
• 401K Plan