Case Manager
South Shore Health, Weymouth, MA, United States
Technology – Embraces technological solutions to work processes and practices.
eDischarge
EHR
Interqual
MCCM
Epic
Workday
Requisition Number:
R-22541
Facility:
LOC0001 - 55 Fogg Road, Weymouth, MA 02190
Department Name:
SSH Care Progression
Status:
Full time
Budgeted Hours:
40
Shift:
Day (United States of America). Mon‑Fri 5‑8s or 4‑10s. Alternating weekends and holidays.
Under the general supervision of the Case Management Manager, the RN Case Manager acts as a patient advocate and case manager to SSH&EC clients. This autonomous role coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost‑efficient patient outcomes. The case manager looks for opportunities to reduce cost while assuring the highest quality of care is maintained. The RN Case Manager applies review criteria to determine medical necessity for admission and continued stay, provides clinically‑based case management, discharge planning, and care coordination to facilitate the delivery of cost‑effective quality healthcare and assists in the identification of appropriate utilization of resources throughout the continuum of care.
He/she works collaboratively with interdisciplinary staff internal and external to the organization, participates in quality improvement and evaluation processes related to the management of patient care, and is on‑site to ensure coverage daily including weekends and holidays.
Compensation Pay Range:
$117,707.20 – $170,768.00
Responsibilities
Review the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
Assist physicians in determining the medical necessity for observation, admission and continued stays using Interqual Criteria, physician certification, and payor specific criteria.
Identify daily cases that fail to meet criteria and refer these cases to appropriate manager or physician advisor for secondary review.
Contact attending physicians daily on cases that lack adequate documentation warranting acute hospitalization, clarifying the necessary clinical documentation required to help support medical necessity.
Contact the attending physician to notify them of decision to issue notice of non‑coverage, explain the UR process and insurance coverage requirements, and obtain physician written concurrence when necessary (e.g., Medicare patients).
Inform the patient and/or next of kin when insurance coverage must be terminated for the current admission and issue the termination letter for the Medicare patient.
Re‑activate insurance coverage when patient condition becomes acute and meets criteria again; issue reinstatement letter.
Continue review of all patients using criteria and determine the need for continued hospitalization based upon third‑party payor/insurance guidelines.
Provide clinical data/information to contracted third‑party payers while patient is hospitalized to ensure continued reimbursement and to avoid delays within 24 hours of request.
Play an essential role in assisting physicians, nursing and staff with accurate determination of a patient’s observation status and preventing delayed discharges of observation patients.
Identify and review observation patients to determine the correct patient level of care daily prior to 12 PM.
Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient and refer questionable status to internal physician advisor or EHR according to departmental process.
Assume the role of review coordinator for observation services; review medical record for appropriateness of status and level of care, and facilitate the level of care using InterQual for Observation.
Work with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
Take telephone orders from physicians changing patient status from observation to inpatient admission as needed, monitoring observation status and communicating promptly with physician.
Participate in case finding and pre‑admission evaluation screening to assure reimbursement.
Identify potential transition planning problems in a timely manner to set up required services.
Work with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals (e.g., SNF/VNA/Home Pharmacy).
Identify need for new resources if gaps exist in service continuum and initiate creative care delivery options.
The RN Case Manager is responsible for assessing patient acute level of care needs and works to implement and coordinate interventions to facilitate a safe and timely discharge plan.
Work with the Case Manager to identify and prioritize workflow through identification of patient‑specific, department‑needs and/or unit‑based needs.
Execute and implement a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
Make and document appropriate changes to discharge plan when necessary.
Proactively uncover barriers to early/timely discharge and overcome them.
Facilitate and coordinate patient care rounds.
Conduct necessary conferences and team meetings regarding specific patient needs.
Implement interventions that lead to patient accomplishing goals established in Plan.
Coordinate necessary resources to accomplish goals developed in Plan.
Proactively affect system to facilitate efficient flow of care, anticipate discharge process.
Gather information from multidisciplinary team and monitor appropriate discharge plan.
Continue clinical duties and administrative tasks.
Use and update the interdisciplinary patient White Board for communication enhancement; including RN Case Manager name, time/date/plan for discharge.
Issue the Medicare Important Message (IM).
Proper use of the Medical Necessity form for post‑discharge transportation.
Use technical tools such as eDischarge, EHR, Interqual, MCCM.
Identify and/or facilitate establishment of a patient’s Health Care Proxy.
Identify patient Care Plan Partner.
Foster patient and family awareness of Patient Portal.
Ensure patient receives all information related to choice of follow‑up care facilities according to patient and family preference and any ACO preferred contracted providers.
Ensure at minimum, 3 referrals are processed for continuum of care providers.
Document choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record.
Expedite and process referrals in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.
Document response by providers.
Deliver the Medicare Important Message (IM) per department protocol.
Have patient, family/healthcare proxy sign discharge plan.
Interact, communicate, and intervene with multidisciplinary healthcare team proactively.
Establish a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
Explore strategies to reduce length of stay and resource consumption within the care managed patient populations, implement and document results.
Communicate to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits to facilitate discharge plan.
Maintain a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
Review physician documentation and follow procedures to seek clarification where indicated relative to diagnosis and comment on patient’s clinical state.
Coordinate and participate in daily multidisciplinary patient care rounds.
Use the SBAR method to communicate with MD and peers.
Act as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning for more clinically complex or long‑length of stay patients.
Establish and maintain effective communication with all referral sources, insurers, vendors and patient supplier systems.
Maintain a professional commitment to institution and departmental goals and flexibility to department’s needs.
Maintain an updated knowledge base of provider benefits for care choices, including public, private, and governmental payers and established/preferred ACO relations.
Maintain working knowledge of the requirements of the payers most frequently seen with the patient population.
Maintain working knowledge of resources available in the community for patients/families.
Maintain current nursing licensure CEU credits, case management certification CEU's.
Maintain Interqual Certification.
Responsible for department operational excellence regarding safe and effective discharge planning and ensuring quality services per policies, procedures, and professional standards.
Manage all activities so that quality services are provided efficiently and effectively.
Ensure services meet all applicable regulatory requirements.
Participate in departmental and organizational quality improvement initiatives involving Lean principles and TIM WOODS.
Maintain departmental productivity measurements.
Be aware of departmental productivity measurements including LOS and utilization.
Follow department policies, procedures, and standards of care that support operational excellence and productivity measurements.
Attain all agreed goals and objectives within specified time frames, as part of overall organizational mission.
Qualifications
Minimum Education:
Registered Nurse, Bachelor’s degree strongly preferred.
Minimum Work Experience:
3‑5 years acute care hospital experience preferred; critical care or emergency department experience highly desirable.
Required Licenses / Registrations:
RN - Registered Nurse.
Required Certifications:
ACM – Accredited Case Manager or CCM – Certified Case Manager within two years of hire.
Knowledge & Abilities:
Demonstrated skills in negotiation, communication, conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, and ability to multitask in a high‑stress environment.
Knowledge of healthcare financing, community and organizational resources, patient care processes, data analysis, utilization management with third‑party payers, and post‑acute care community resources.
Experience with managed care preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Shift: Mon‑Fri 5‑8s or 4‑10s. Alternating weekends and holidays.
#J-18808-Ljbffr
eDischarge
EHR
Interqual
MCCM
Epic
Workday
Requisition Number:
R-22541
Facility:
LOC0001 - 55 Fogg Road, Weymouth, MA 02190
Department Name:
SSH Care Progression
Status:
Full time
Budgeted Hours:
40
Shift:
Day (United States of America). Mon‑Fri 5‑8s or 4‑10s. Alternating weekends and holidays.
Under the general supervision of the Case Management Manager, the RN Case Manager acts as a patient advocate and case manager to SSH&EC clients. This autonomous role coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost‑efficient patient outcomes. The case manager looks for opportunities to reduce cost while assuring the highest quality of care is maintained. The RN Case Manager applies review criteria to determine medical necessity for admission and continued stay, provides clinically‑based case management, discharge planning, and care coordination to facilitate the delivery of cost‑effective quality healthcare and assists in the identification of appropriate utilization of resources throughout the continuum of care.
He/she works collaboratively with interdisciplinary staff internal and external to the organization, participates in quality improvement and evaluation processes related to the management of patient care, and is on‑site to ensure coverage daily including weekends and holidays.
Compensation Pay Range:
$117,707.20 – $170,768.00
Responsibilities
Review the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
Assist physicians in determining the medical necessity for observation, admission and continued stays using Interqual Criteria, physician certification, and payor specific criteria.
Identify daily cases that fail to meet criteria and refer these cases to appropriate manager or physician advisor for secondary review.
Contact attending physicians daily on cases that lack adequate documentation warranting acute hospitalization, clarifying the necessary clinical documentation required to help support medical necessity.
Contact the attending physician to notify them of decision to issue notice of non‑coverage, explain the UR process and insurance coverage requirements, and obtain physician written concurrence when necessary (e.g., Medicare patients).
Inform the patient and/or next of kin when insurance coverage must be terminated for the current admission and issue the termination letter for the Medicare patient.
Re‑activate insurance coverage when patient condition becomes acute and meets criteria again; issue reinstatement letter.
Continue review of all patients using criteria and determine the need for continued hospitalization based upon third‑party payor/insurance guidelines.
Provide clinical data/information to contracted third‑party payers while patient is hospitalized to ensure continued reimbursement and to avoid delays within 24 hours of request.
Play an essential role in assisting physicians, nursing and staff with accurate determination of a patient’s observation status and preventing delayed discharges of observation patients.
Identify and review observation patients to determine the correct patient level of care daily prior to 12 PM.
Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient and refer questionable status to internal physician advisor or EHR according to departmental process.
Assume the role of review coordinator for observation services; review medical record for appropriateness of status and level of care, and facilitate the level of care using InterQual for Observation.
Work with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
Take telephone orders from physicians changing patient status from observation to inpatient admission as needed, monitoring observation status and communicating promptly with physician.
Participate in case finding and pre‑admission evaluation screening to assure reimbursement.
Identify potential transition planning problems in a timely manner to set up required services.
Work with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals (e.g., SNF/VNA/Home Pharmacy).
Identify need for new resources if gaps exist in service continuum and initiate creative care delivery options.
The RN Case Manager is responsible for assessing patient acute level of care needs and works to implement and coordinate interventions to facilitate a safe and timely discharge plan.
Work with the Case Manager to identify and prioritize workflow through identification of patient‑specific, department‑needs and/or unit‑based needs.
Execute and implement a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
Make and document appropriate changes to discharge plan when necessary.
Proactively uncover barriers to early/timely discharge and overcome them.
Facilitate and coordinate patient care rounds.
Conduct necessary conferences and team meetings regarding specific patient needs.
Implement interventions that lead to patient accomplishing goals established in Plan.
Coordinate necessary resources to accomplish goals developed in Plan.
Proactively affect system to facilitate efficient flow of care, anticipate discharge process.
Gather information from multidisciplinary team and monitor appropriate discharge plan.
Continue clinical duties and administrative tasks.
Use and update the interdisciplinary patient White Board for communication enhancement; including RN Case Manager name, time/date/plan for discharge.
Issue the Medicare Important Message (IM).
Proper use of the Medical Necessity form for post‑discharge transportation.
Use technical tools such as eDischarge, EHR, Interqual, MCCM.
Identify and/or facilitate establishment of a patient’s Health Care Proxy.
Identify patient Care Plan Partner.
Foster patient and family awareness of Patient Portal.
Ensure patient receives all information related to choice of follow‑up care facilities according to patient and family preference and any ACO preferred contracted providers.
Ensure at minimum, 3 referrals are processed for continuum of care providers.
Document choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record.
Expedite and process referrals in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.
Document response by providers.
Deliver the Medicare Important Message (IM) per department protocol.
Have patient, family/healthcare proxy sign discharge plan.
Interact, communicate, and intervene with multidisciplinary healthcare team proactively.
Establish a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
Explore strategies to reduce length of stay and resource consumption within the care managed patient populations, implement and document results.
Communicate to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits to facilitate discharge plan.
Maintain a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
Review physician documentation and follow procedures to seek clarification where indicated relative to diagnosis and comment on patient’s clinical state.
Coordinate and participate in daily multidisciplinary patient care rounds.
Use the SBAR method to communicate with MD and peers.
Act as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning for more clinically complex or long‑length of stay patients.
Establish and maintain effective communication with all referral sources, insurers, vendors and patient supplier systems.
Maintain a professional commitment to institution and departmental goals and flexibility to department’s needs.
Maintain an updated knowledge base of provider benefits for care choices, including public, private, and governmental payers and established/preferred ACO relations.
Maintain working knowledge of the requirements of the payers most frequently seen with the patient population.
Maintain working knowledge of resources available in the community for patients/families.
Maintain current nursing licensure CEU credits, case management certification CEU's.
Maintain Interqual Certification.
Responsible for department operational excellence regarding safe and effective discharge planning and ensuring quality services per policies, procedures, and professional standards.
Manage all activities so that quality services are provided efficiently and effectively.
Ensure services meet all applicable regulatory requirements.
Participate in departmental and organizational quality improvement initiatives involving Lean principles and TIM WOODS.
Maintain departmental productivity measurements.
Be aware of departmental productivity measurements including LOS and utilization.
Follow department policies, procedures, and standards of care that support operational excellence and productivity measurements.
Attain all agreed goals and objectives within specified time frames, as part of overall organizational mission.
Qualifications
Minimum Education:
Registered Nurse, Bachelor’s degree strongly preferred.
Minimum Work Experience:
3‑5 years acute care hospital experience preferred; critical care or emergency department experience highly desirable.
Required Licenses / Registrations:
RN - Registered Nurse.
Required Certifications:
ACM – Accredited Case Manager or CCM – Certified Case Manager within two years of hire.
Knowledge & Abilities:
Demonstrated skills in negotiation, communication, conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, and ability to multitask in a high‑stress environment.
Knowledge of healthcare financing, community and organizational resources, patient care processes, data analysis, utilization management with third‑party payers, and post‑acute care community resources.
Experience with managed care preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Shift: Mon‑Fri 5‑8s or 4‑10s. Alternating weekends and holidays.
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