Registered Nurse - (RN) - Case Manager - Emergency Services - FT - Nights

Northeast Georgia Health System•Gainesville, GA

About The Position

The Admissions/ED Case Manager works to ensure appropriateness of patients to be bedded at or transferred to NGHS. This position will either evaluate NGHS ED patients for appropriateness of admission and/or coordinate in-bound transfers/direct admits from primary care providers offices, free standing emergency clinics (Urgent Care) and patients from regional community hospitals who require a higher level of care. This position will compare services being requested to nationally recognized medical necessity criteria to attain appropriate bedded status. The position will be accountable to refer patients to the physician advisors per organization guidelines and work collaboratively with the patient's physician to ensure appropriate level of care. The position will be responsible for identifying inappropriate admissions/transfers and either coordinating an appropriate discharge plan to meet the patient's needs or declining transfers in conjunction with the physician advisor. Works collaboratively with the physicians, patient/family, nursing, utilization review and other members of the healthcare team to assure patient management that efficiently and effectively aligns with patient needs using resources to meet quality, clinical and cost effective outcomes. Coordinates a team approach designed to facilitate the achievement of expected patient outcomes with appropriate transitions to the next level of care. This position will come in contact with patients in the neonate, infant, child, adolescent, adult and geriatric age groups. Employees will perform clinical duties in accordance with population specific guidelines and adhere to National Patient Safety Guidelines.

Requirements

Professional RN licensure, Active GA licensure.
Associate degree. Graduate of an accredited school of nursing.
Three (3) to five (5) years of experience in direct patient care and/or case management.
Must demonstrates excellent clinical knowledge skills, observation skills, and organizational skills
Demonstrates excellent written and verbal communication skills and be self-directed
Requires proficiency with computers and software, financial analytical and problem solving skills, and the ability to collect data
Demonstrates interpersonal skills including professionalism, a team player, and a positive approach to situations
Requires working knowledge of medical necessity criteria and application of admission criteria
Working knowledge of state and federal regulations and medical necessity criteria

Nice To Haves

Case Mgmt Certification (CCM or ACM) preferred
Bachelors Degree
Discharge planning and utilization review experience is recommended.

Responsibilities

Determines if patients meet nationally recognized medical necessity criteria for admission/transfer into the system.
Coordinates appropriate patient entry into NGMC's acute beds, utilizing clinical criteria to assess medical appropriateness and patient status.
Refers appropriate cases to physician advisors for review and status determination.
Communicates with physician to obtain appropriate status order based on E.H.R. determination.
Utilizes second level review process per established guidelines and provides appropriate documentation of referral and outcome.
Identifies and reports clinical transfer issues, utilizing knowledge of EMTALA laws, medical necessity, and reimbursement up the chain of command.
Adheres to all regulatory and DNV requirements.
Provides consistently legible documentation and/or signatures.
Documents orders received appropriately, including date and time.
Knowledgeable of third party/governmental payer regulatory requirements and in and out of network coverage benefits, and adheres to appropriate processes/completes paperwork as required.
Maintains confidentiality and respects patients privacy.
Performs in a manner that respects HIPPA laws.
Promotes compliance with external regulatory and health plan standards and requirements to facilitate accurate reimbursement
Assists other team members to accomplish their job duties.
Must demonstrate data entry/retrieval and other computer experience as necessary, and accurately completes all documentation required for all transactions.
Actively supports a customer service oriented environment to continually enhance customer satisfaction.
Communicates directly with physicians and referring facilities to ensure collaborative practice.
Contributes to the productive and effective operation of the Care Coordination area.
Reports problems as opportunities for improvement up the chain of command.
Coordinate and communicate with Utilization Review Nurse on a daily, consistent basis to ensure patients are in the right status and level of care.
Facilitate changes by communicating with Physician, mid-level or nursing staff as needed.
Provides utilization and resource management by placing appropriate initial patient status on all patients bedded, to include ED admissions, direct admits or as a result of a transfer from another acute care facility.
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.