Job Number:

35068

Location:

Worth Campus

Street Address:

807 S Isabella St

City, State:

Sylvester, Georgia

Zip Code:

31791

Department:

PWMC UTILIZATION REVIEW

Shift:

Days

Job Type:

Full time

Posted Date:

2026-09-10

Job Description Summary:

The Nurse Case Manager (CM) is responsible for care coordination of patients along their continuum from point of entry through discharge. The CM will address issues related to appropriate and timely admission, discharge, and care for patients receiving inpatient and observation care and services at PPHS facilities. The Care Manager performs first level clinical reviews according to hospital approved clinical criteria and in accordance with the Care Management Program's Utilization Plan and payer specific requirements. He/she will address utilization of resources for efficient and effective care delivery at the appropriate level of care. The Care Manager collaborates with social work, physicians, nurses and multidisciplinary team, lending professional care management expertise to ensure quality, timely and cost effective case management for an identified patient population and addresses issues or patterns in patient readmission. In this role the Care Manager is accountable for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes. Under the direction of the Care Management Team Lead,
the Director of Care Management, and through coordination with nursing, social work, physicians and other members of the interdisciplinary team, the Care Manager develops, facilitates and implements appropriate case management and discharge plans.

Description:

Job Summary
The Nurse Case Manager (CM) is responsible for care coordination of patients along their continuum from point of entry through discharge. The CM will address issues related to appropriate and timely admission, discharge, and care for patients receiving inpatient and observation care and services at PPHS facilities. The Care Manager performs first level clinical reviews according to hospital approved clinical criteria and in accordance with the Care Management Program's Utilization Plan and payer specific requirements. He/she will address utilization of resources for efficient and effective care delivery at the appropriate level of care. The Care Manager collaborates with social work, physicians, nurses and multidisciplinary team, lending professional care management expertise to ensure quality, timely and cost effective case management for an identified patient population and addresses issues or patterns in patient readmission. In this role the Care Manager is accountable for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes. Under the direction of the Care Management Team Lead,
the Director of Care Management, and through coordination with nursing, social work, physicians and other members of the interdisciplinary team, the Care Manager develops, facilitates and implements appropriate case management and discharge plans.

Qualifications
Associate's Degree in Nursing from a state accredited school (Required)
Bachelor's Degree in from a state accredited School of Professional Nursing (Preferred)

Work Experience
3 or more years of recent acute care experience with relevant clinical experience in the assigned area. (Required)
1 or more years of Case Management or Utilization Review experience in a hospital or related setting. (Preferred)

Licenses and Certifications
Registered Nurse (RN) with current Georgia license (Required)
Certified Case Manager (CCM) (Preferred)

Essential Functions
JOB KNOWLEDGE - CARE MANAGER:
Understands and fulfills job responsibilities and expectations and applies knowledge and skills to function proficiently in CM role.
Serves as Patient Advocate in support of Hospital mission and goals.
Maintains knowledge of current federal, state and accreditation requirements applicable to utilization review and discharge planning; demonstrates skill in the application of this knowledge.
Possesses current and comprehensive skill and knowledge to perform all parts of the job effectively and efficiently.
Exhibits ability to learn and apply new skills, professional knowledge and expertise.
Requires minimal day-to-day direction to perform responsibilities.
Acts as resource in area of specialty and is able to share best practices and answer questions as needed.

UTILIZATION MANAGEMENT AND DISCHARGE PLANNING:
Performs utilization review and discharge/transition planning functions and activities per assigned caseload or unit.
Applies knowledge of regulations and payer requirements to maintain full compliance, assure patient rights and avert payer denials or patient liability
Notifies the Physician Adviser designee, or Chief Utilization Officer, as needed regarding physician issues, patient care issues or quality issues. Seeks guidance and intervention as necessary; discusses or escalates cases to Team Lead or Director CM for guidance or administrative support.
Performs prospective or concurrent review of patient medical records; applies established clinical criteria for admission and continued stay based on severity of illness and intensity of service needs; may perform retrospective review of same as required.
Educates physicians, nurses and other hospital personnel regarding CM processes, and payer or regulatory agency policies and regulations.
Ensures that an appropriate plan-of-care has been established, including an appropriate discharge plan. Intervenes and facilitates as needed. Serves as a resource to nursing staff and social workers in complex patient discharge issues.
Provides patient/family specific education regarding discharge services, options, and providers of care or services.
Discusses payer authorizations or actions needed by patient/family to secure financial obligations for transition planning needs.
Assesses clinical evaluations and documentation related to assigned patients' medical diagnosis and clinical treatment plan; considers impact of plan along with emotional, cultural and psychosocial factors.
Identifies patient and family needs related to medical diagnosis, treatment plan, care options and financial resources for discharge planning. Identifies risk factors and makes timely referrals to appropriate disciplines, agencies, or community resources.
Identifies actual or potential delays in care, particularly those which may result in issues with quality of care, lack of medical necessity or payment/authorization denial. Intervenes with physicians, nursing and other health system departments to promote timeliness of care and service and to prevent delays in care.

ASSESSMENT, COORDINATION AND PLANNING:
Performs care management assessment for patient appropriate level of care and treatment setting.
Formulates an individualized patient plan and coordinates with Social Worker to determine priorities for timely planning and safe transition. Facilitates the coordination of care among caregivers, and across acute and post-acute care settings.
Performs clinical and CM assessment, with input from the physician, nurse and interdisciplinary team; issues are identified and goals for transition are developed.
Patient, family or significant other, as legally appropriate, is engaged to participate in planning and decisions.
Performs systematic assessment and periodic reassessment of patient/family needs according to clinical status, treatment and response to care.
Prioritizes data collection based on the patient's condition and needs.
Identifies expected outcomes and plan based on diagnoses or issues.
Evaluates the plan in relation to patient responses and expected outcomes.
Documents the results of the evaluation.

CM - LEADERSHIP:
Engages in teamwork as a team player and a team leader.
Educates staff, physicians and patients about the role of Care Manager.
Serves on committees or participates in projects at work with opportunities for shared decision making and being a change agent.
Promotes professionalism of care management role through participation in professional organizations.
Incorporates evidence based knowledge in practice.

PERFORMANCE IMPROVEMENT AND OUTCOMES:
Develops expected actions and strategies that positively impact care coordination, efficiency and effectiveness.
Uses creativity and innovation to improve CM work, patient flow, and hospital efficiency.
Identifies patterns or trends that can positively impact readmissions.
Involves patient/family and other disciplines to determine expected outcomes.
Includes the patient and others involved in the care in the evaluation process.
Modifies expected outcomes based on changes in the assessment of the patient.
Assesses patterns, trends or root cause of readmission for individual patient or across assigned areas.
Works with social worker, nursing, physician and others to proactively address patient specific issues to avert future readmits.
Evaluates issues related to clinical management, patient adherence or discharge planning that are factors for readmission.
Incorporates evidence based knowledge to initiate change. Participates in quality improvement activities.

DOCUMENTATION & ELECTRONIC SYSTEM:
Documents and records review activity, follow up and outcomes in the appropriate electronic system as required; assures documented/recorded information and data are timely and inclusive of pertinent facts.
Clearly and accurately documents CM related reviews, referrals, activities related to transition planning and outcomes.
Ensures that documentation is tailored to expected readers / users.
Uses correct terminology in accordance with hospital standards and conforms to required style and format.

Additional Duties
Adheres to the hospital and departmental attendance and punctuality guidelines.
Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
Performs other duties as required and completes all job functions as per departmental policies and procedures.
Maintains current knowledge in present areas of responsibility (i.e., self education, attends ongoing educational programs).
Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs.

For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.
Wears protective clothing and equipment as appropriate.