Mgr RN Case

Position Summary

To perform the activities of Case Management and Utilization Management to facilitate the collaborative management for an entire episode of care for all patients with the multidisciplinary health care team, focusing on resource management and discharge planning. Performs timely review and delivery of necessary clinical information according to governmental regulations and insurance guidelines for approval of hospital care and correct admission status optimizing appropriate reimbursement for services, while supporting the mission of Williamson Health.

• Must be currently licensed by the State of Tennessee as a Registered Nurse.
• Emergency Room and/or Critical Care preferred.
• Case Management Certification preferred/required within 3 years of employment.
• Earned a nursing diploma or degree from a college or university.
• Recent minimum 5 years related experience in hospital or managed care setting.
• Prior utilization/case management experience preferred.

• Demonstrated clinical knowledge base in medical/surgical nursing and/or critical care.
• Demonstrated organization, time management, problem‑solving, and critical thinking skills.
• Able to perform independently and in team situations under the supervision of a Director/Manager.
• Demonstrated effective verbal and written communication skills.
• Efficient review and interpretation of the medical record.
• Familiar with Meditech, Allscripts Care Management, Fax, Copier, basic computer skills preferred.
• General knowledge of Governmental and Insurance guidelines related to case management compliance, reimbursement, DRG system and Interqual Criteria preferred.
• Positive attitude with a willingness to learn new processes and adjust well to change.
• Required weekend rotation.

Office and clinical environment. Possible exposure to airborne pathogens.

• Telephone and computer use for extended periods of time.
• Able to walk/stand, up to 2 hours/day.
• Clear legible handwriting.
• Clear understandable voice.

• Consistently sets priorities and exhibits efficient time‑management skills with assigned workload within the confinements of scheduled shift.
• Timely reviews patients within 24 hours or next business day after admission and at a minimum of every 2 days thereafter for continued stay, applying appropriate criteria (Interqual) and facilitating reimbursement for services with third payer parties, obtaining and entering authorization number/approval status and notes in Meditech.
• Completes assessments and initial status revision within 24 hours or next business day, documenting in Meditech/Allscripts.
• Maintains precise, timely, and appropriate documentation in Allscripts and Meditech. Maintains legible, pertinent documentation on the patient's hard copy face sheet.
• Maintains knowledge of assigned patient's clinical condition, plan of care, discharge plan and payer source information as demonstrated in group and individual discussions.
• Timely delivery of the Initial and Follow‑up Important Message Notification according to departmental policy for 75% of assigned and appropriate patients.
• Assists in patient conversations and delivery of information related to discharge choices/discharge appeals and actively facilitates in the Discharge Appeals process.
• Initiates peer‑to‑peer and initial appeal process as shown by consistent, clear communication to the physician and denials/appeals coordinator within 24 hours or next business day of notification of denial and documentation in Meditech/Allscripts &/or BAR.
• Accurate and timely completion of all steps of the code 44 process after referral to E HR for those patients not meeting admission criteria. Complete documentation which includes hard copy forms, ensuring the status order is entered and correct in the Medical Record followed by documentation in Meditech, BAR and condition code is entered.
• Timely notification to Physician, social worker, and patient of NOTA status with delivery of ABN, HINN‑1 or HINN‑10 when appropriate.
• Collects and enters avoidable days, saved days and denied days in Allscripts, reporting trends to Director/Manager.

• Medical, Dental, Vision
• PTO
• Retirement Match
• Tuition reimbursement
• Discount programs
• FSA (Flexible Spending Accounts)
• Identity Theft Protection
• Legal Aid

Williamson Health is an equal‑opportunity employer and a drug‑free workplace.