Registered Nurse - (RN) - Case Manager - FT - Days

Northeast Georgia Health System•Gainesville, GA

About The Position

The ED Admissions Case Manager evaluates and screens emergency department admissions using screening guidelines to determine the appropriate patient status and level of care based on physician documentation. The role collaborates with physicians, patients and families, and other healthcare team members to establish an appropriate plan of care and ensure services are appropriate. It provides comprehensive assessment, planning, implementation, and evaluation of individual patient needs, and coordinates a team approach to achieve expected patient outcomes and facilitate transitions to the next level of care. The position also provides cross-coverage for other ED RN Case Managers as required. In the Emergency Department and Observation Unit (COU, EOU, MOU), the case manager coordinates and facilitates care so required interventions occur in sequence and without avoidable delay. The role assesses and coordinates discharge plans, arranges post-acute needs when applicable, communicates plans with patients, families, physicians, and the care team, and reassesses plans throughout the stay to support safe, timely transitions.

Requirements

Active professional Registered Nurse licensure in Georgia.
Associate degree and graduation from an accredited school of nursing.
One to two years of experience in Utilization Management applying screening guidelines such as InterQual or MCG, or other related case management experience.
Three to five years of experience in direct patient care and/or case management.
Clinical aptitude, knowledge, and critical-thinking skills in a fast-paced ED environment.
Working knowledge of state and federal regulations, third-party and governmental payer requirements, and in-network and out-of-network coverage benefits.
Excellent observation, analytical thinking, problem-solving, written communication, and verbal communication skills.
Computer and software proficiency.
Knowledge of financial and reimbursement criteria for all payors.
Interpersonal skills, professionalism, teamwork, and a positive approach to situations.
Ability to work in a self-directed manner.

Nice To Haves

Case Management certification (CCM or ACM).
Bachelor's degree.
Acute Care utilization review or case management experience.

Responsibilities

Evaluate ED admissions using screening guidelines, including InterQual or MCG, to determine medical necessity, patient class, and level of care based on physician documentation.
Coordinate appropriate patient entry into NGMC acute beds and communicate with physicians and referring facilities to support collaborative practice.
Refer appropriate cases to physician advisors for review and status determination, and communicate with physicians to obtain the appropriate status order.
Work with physicians, nursing staff, and the care team to support expected length of stay, timely discharge, and transition to the next level of care.
Communicate and coordinate with the care team to ensure patients are in the appropriate status and level of care, while supporting customer satisfaction.
Follow regulatory and DNV requirements and apply knowledge of third-party payer requirements to support appropriate outcomes and coverage of services.
Provide physician education and feedback regarding status determinations and documentation supporting medical necessity.
Maintain confidentiality and respect patient privacy in accordance with HIPAA requirements.
Contribute to effective Care Coordination operations and escalate opportunities for process improvement.
Coordinate and facilitate patient care in the ED and Observation Unit, identify potential service delays, and escalate unresolved delays to management.
Assess, coordinate, and facilitate discharge plans, securing post-acute needs before discharge when applicable.
Communicate discharge plans and information about the plan of care and financial responsibility for inpatient or post-hospitalization services to patients, families, physicians, and other care team members as appropriate.
Reassess discharge plans throughout the patient's stay to support timely, safe discharge and appropriate transitions.
Provide cross-coverage for other ED RN Case Managers as required.