Case Manager

Cape Cod Healthcare•Hyannis, MA

11d

About The Position

The Case Manager supports discharge planning, utilization review, and coordination of patient care. The role screens new admissions daily for discharge planning needs, prioritizes visits, verifies demographic and payer information, and completes initial assessments and reassessments using InterQual® for patients with identified follow-up needs. The Case Manager reviews admission and level-of-care appropriateness, coordinates notices and patient appeal rights, identifies complex psychosocial, financial, and legal needs, and supports third-party reimbursement through timely responses to payer requests. Working with attending physicians and the interdisciplinary team, the Case Manager promotes appropriate care, consistent care and discharge plans, safe transfers, and effective post-hospital care. The position advocates for patients and families, participates in rounds and care conferences, monitors length of stay and denial risk, makes appropriate referrals, assists medical coders, and maintains knowledge of clinical, regulatory, and payer requirements. The role also follows departmental policies and standards, participates in required education and meetings, and provides service consistent with Cape Cod Hospital’s CARES commitment.

Requirements

Ability to read, write, and communicate in English.
Current registration as a Registered Nurse in the Commonwealth of Massachusetts.
At least three years of acute-care experience within the past five years, with broad clinical experience in a hospital setting or case management.
Recent knowledge or experience in discharge planning and utilization review within the past four years.
Working knowledge of InterQual® or an equivalent system.
Strong interpersonal and negotiation skills, with a positive, pleasant, professional, and cooperative demeanor when working with patients, physicians, coworkers, and insurance companies.
Excellent organization and time-management skills.
Ability to work independently and effectively in a fast-paced environment.
Ability to work productively in a stressful environment and handle multiple projects and changing priorities effectively.
Proficient computer skills and ability to use and integrate updated software systems into practice.

Nice To Haves

Bachelor of Science Degree in Nursing preferred for external applicants.
Certificate in Case Management, CPUM, or a specialty preferred.

Responsibilities

Screen new admissions daily for discharge planning needs, prioritize visits based on screening criteria, and notify admissions of corrections to demographic or payer information.
See patients with identified follow-up needs within one business day and complete Initial Assessments in InterQual®; complete reassessments every three days as needed for changes in medical status, diagnosis, or caregiver.
Review admission appropriateness and Inpatient or Observation level-of-care needs using InterQual® Criteria, and follow policy and procedure when criteria are not met.
Initiate timely HINN Notices and letters of reinstatement, and coordinate patient appeal rights under the Discharge Appeals program.
Identify patients and families with high-risk complex psychosocial, financial, or legal needs and refer them to appropriate resources.
Perform utilization review on the assigned unit and respond to third-party payer requests for concurrent clinical information by day end.
Work with attending physicians and the interdisciplinary team to facilitate appropriate care and services, ensuring care and discharge plans align with patient needs and covered services.
Participate in or facilitate daily unit rounds.
Advocate for patients by partnering with families, payers, and the healthcare team; communicate adverse determinations and insurance coverage or ongoing-care issues; and support patient independence in decision making when appropriate.
Coordinate and communicate complete referral information and paperwork to support safe transfers to other facilities or agencies.
Use knowledge of community resources and act as a staff resource for safe and effective post-hospital care.
Apply approved standards of care, Care Maps, and clinical pathways to evaluate and monitor patients’ clinical courses; participate in pathway development and revision and in care conferences across the continuum.
Evaluate continued length of stay using recognized InterQual® criteria and refer to the Physician Advisor when criteria are not met and resolution with the attending physician is not achieved.
Identify days at risk for denial and initiate strategies to facilitate care and discharge.
Assist medical coders by obtaining diagnostic and procedural information needed to support appropriate reimbursement.
Maintain departmental policies and procedures, objectives, quality assurance, safety, environmental, and infection-control standards.
Maintain clinical competency and current knowledge of regulatory and payer requirements.
Participate in required education programs, in-services, and meetings.
Work independently, comply with dress-code policies, and perform other related duties as assigned or requested.
Demonstrate flexibility, cooperation, and teamwork, and provide service consistent with Cape Cod Hospital’s CARES commitment.