Registered Nurse - (RN) - ED Admission Utilization Management Experience

Job Category

Nursing - Registered Nurse

Work Shift/Schedule

8 Hr Afternoon - Evening

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

About the Role

Job Summary

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.

Minimum Job Qualifications

* 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 Job Qualifications

* 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:

Job Specific and Unique Knowledge, Skills and Abilities

* 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. 

Essential Tasks and Responsibilities

* 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.

Area/Unit Specific Essential Tasks and Responsibilities: Emergency Department

AND OBSERVATION UNIT (COU, EOU, MOU)

* 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.

Physical Demands

* 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.