Optim Medical Center - Tattnall is seeking a full time RN Case Manager for our Reidsville, GA location.

Job Requirements:

• Maintains medical and orthopedic surgical patients in appropriate level of care.
• Obtains prior authorization from insurance on newly admitted medical patients.
• Makes notification of admission and discharge on Inpatient orthopedic and spine surgery patients.
• Provides medical necessity updates to insurance companies on all admissions requiring additional stay beyond approval.
• Writes appeal letters for denials and reviews with physicians on appropriate level of care based on Milliman Care Guidelines (MCG) criteria.
• Completes DMA6 and Level 1 paperwork for patients being admitted/transferred to Swing bed, Skilled Nursing Facility, or Nursing Home placement.

QUALIFICATIONS:

1. Possession of a valid state license as a registered nurse

2. Possession of Basic Life Support, ACLS, and PALS certifications

3. Ability to develop policies and procedures

4. Possess creative abilities to develop education tools

5. Excellent written and verbal skills

6. Ability to teach and evaluate clinical performance of staff

7. Ability to teach patients/families and evaluate the response and retention of information

DUTIES AND RESPONSIBILITIES:

1. Performs admission, concurrent, and focused reviews using criteria as specified by payor and maintains contact with payor as specified until patient's discharge.

2. Maintains computer or paper record of data obtained from admission, concurrent, and focused reviews.

3. Performs or assists in retrospective reviews or studies following designated guidelines established by various clinical disciplines.

4. Consults with admitting physician or physician advisor regarding specific patients as required.

5. Assists Utilization Review Committee in identifying areas of mis-utilization.

6. Prepares for on-site monitoring reviews by Blue Cross, PRO, and various third-party review organizations.

7. Compliments activities of existing internal hospital utilization review and medical audit activities.

8. Reviews charts daily, collects the necessary data and for the review, and prepares documentation for the review.

9. Assumes active role in implementation, monitoring, and evaluation of utilization review.

10. Refers all questionable admissions and possible extensions of length of stay to Utilization Review Committee for reviewing.

11. Gives prompt written and oral notification when the final determination of the committee or subcommittee is that hospitalization is not medically necessary or that further stay is not considered medically necessary, therefore not being payable by the program involved.

Optim Offers:

• Competitive Pay
• Company Benefits
• Vacation, Personal Time Off, and Sick Leave
• Holiday Pay
• 401K Plan