Registered Nurse RN - Case Manager - Emergency Services

Job Category

Registered Nurse – Nursing

12 Hr Morning – Evening

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

The Admissions/ED Case Manager works to ensure appropriateness of patients to be bedded at or transferred to NGHS. This position evaluates NGHS ED patients for appropriateness of admission and/or coordinates inbound transfers/direct admits from primary care provider offices, free standing emergency clinics (Urgent Care), and patients from regional community hospitals who require a higher level of care. This position compares services requested to nationally recognized medical necessity criteria to attain appropriate bedded status.

The position refers patients to the physician advisors per organization guidelines and works collaboratively with the patient's physician to ensure appropriate level of care. This position identifies inappropriate admissions/transfers and coordinates an appropriate discharge plan or declines transfers in conjunction with the physician advisor. The role works collaboratively with physicians, patients/families, nursing, utilization review, and other members of the healthcare team to assure patient management that is efficient, effective, and aligned with patient needs, using resources to meet quality, clinical and cost‑effective outcomes.

The position 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 perform clinical duties in accordance with population‑specific guidelines and adhere to National Patient Safety Guidelines.

• Licensure:
  Professional RN licensure, active GA licensure
• Education:
  
  Associates Degree, graduate of an accredited school of nursing
• Experience:
  
  Three (3) to five (5) years in direct patient care and/or case management

• Case Management Certification (CCM or ACM) preferred
• Bachelor’s Degree
• Discharge planning and utilization review experience recommended

• Excellent clinical knowledge, observation, and organization
• Excellent written and verbal communication, self‑directed
• Proficiency with computers and software, financial analysis, problem solving, data collection
• Interpersonal skills: professionalism, team player, positive approach
• Knowledge of medical necessity criteria and admission criteria
• Knowledge of state and federal regulations and medical necessity criteria

• Determine if patients meet nationally recognized medical necessity criteria for admission/transfer into the system
• Coordinate appropriate patient entry into NGMC’s acute beds, utilizing clinical criteria to assess medical appropriateness and patient status
• Refer appropriate cases to physician advisors for review and status determination
• Communicate with physician to obtain appropriate status order based on electronic health records determination
• Utilize second‑level review process per established guidelines and provide appropriate documentation of referral and outcome
• Identify and report clinical transfer issues, utilizing knowledge of EMTALA laws, medical necessity, and reimbursement
• Adhere to all regulatory and DNV requirements, provide consistently legible documentation, and document orders appropriately with date and time
• Maintain knowledge of third‑party/governmental payer regulatory requirements and network coverage benefits, and complete paperwork as required
• Maintain confidentiality and respect patients’ privacy; perform in a manner that respects HIPAA laws
• Promote compliance with external regulatory and health plan standards and requirements to facilitate accurate reimbursement
• Assist other team members to accomplish their job duties; demonstrate data entry/retrieval and computer experience as necessary, and complete all documentation required for all transactions
• Actively support a customer‑service oriented environment to…