SummaryLocated in Franklin, Tennessee, Williamson Health is one of the South's most exceptional health care systems with a 203 bed hospital (Williamson Medical Center), over 40 providers at our Williamson Health Medical Group locations, the Bone & Joint Institute and the Monroe Carell Junior Children's Hospital Vanderbilt at Williamson Medical Center. Williamson Health offers comprehensive in-patient and out-patient services. We have more than 825 providers representing over 70 medical specialties and sub-specialties.
Williamson Health is a system where your talents will be valued and your skillset expanded. We are rooted in our promise to world-class, compassionate care for the residents of Williamson County and surrounding communities, taking exceptional pride in serving our community. We're committed to empowering our employees to work in innovative ways and reserve time and space for curiosity, laughter and creativity. We value and support the diversity and cultural differences among one another and are committed to upholding an inclusive environment that appreciates the uniqueness of all individuals. Our values are at the heart of everything we do: respect for every individual, the health and total well-being of all people, human compassion and integrity. These shape who we are as an organization and are essential for delivering the highest level of culturally competent care and treatment of every patient, family member, visitor, physician and employee.
Williamson Health is pleased to offer a comprehensive benefits program, that offers you choice and flexibility, so you can take charge of your physical, financial, and emotional well-being.
o Medical, Dental, Vision
o PTO
o Retirement Matching
o Tuition reimbursement
o Discount programs
o FSA (Flexible Spending Accounts)
o Identity Theft Protection
o Legal Aid
Williamson Health is an equal-opportunity employer and a drug-free workplace.
POSITION SUMMARYTo 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.
POSITION REQUIREMENTSFormal Education / Training:
- 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
Workplace Experience:
Recent minimum 5 years related experience in hospital or managed care setting.
Prior utilization/case management experience is preferred.
Equipment and Skills Training:
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 adjusts well to change.
Required Weekend Rotation
Physical Environment:
Office and Clinical environment.
Possible exposure to airborne pathogens.
Physical Effort:
Telephone and computer use for extended periods of time.
Able to walk/stand, up to 2 hours/day.
Clear legible handwriting
Clear understandable voice.
PERFORMANCE STANDARDS - 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
