Case Manager

Cape Cod Healthcare•Hyannis, MA

1d•Onsite

About The Position

The Case Manager is responsible for screening new admissions daily for discharge planning needs, establishing visit priorities, and verifying demographic and payer information. They conduct initial assessments within one business day of identification for patients with identified needs, and perform reassessments every three days as needed. The role involves reviewing the appropriateness of patient admissions and level of care using InterQual® Criteria, initiating HINN Notices, and coordinating patient appeal rights. The Case Manager identifies and refers patients with complex psychosocial, financial, and legal needs to appropriate resources. They are responsible for utilization review, facilitating third-party reimbursement by responding to payer requests, and working closely with the interdisciplinary team to ensure the care plan and discharge plan meet patient needs. This role includes participating in daily rounds, advocating for patients, communicating with patients/families regarding adverse determinations, and facilitating patient independence in decision-making. Additionally, they coordinate and communicate referral information for safe patient transfers, complete necessary paperwork, and apply approved standards of care. The Case Manager evaluates continued length of stay for appropriateness, makes referrals to the Physician Advisor if criteria are not met, and identifies days at risk for denial. They also assist medical coders with diagnostic and procedural information for reimbursement and maintain departmental policies, procedures, and standards. The position requires maintaining core/clinical competency, current knowledge of regulatory and payer requirements, and participation in education programs. The role demands accountability, initiative, and the ability to work independently, cooperatively, and with a team. Service excellence is expected in all interactions, reflecting the hospital's commitment to CARES (compassion, accountability, respect, excellence, and service).

Requirements

Ability to work independently.
Complies with policies regarding dress code.
Ability to read, write and communicate in English.
Current registration as a Registered Nurse in the Commonwealth of Massachusetts.
Minimum of 3 years acute care experience within the past 5 years with broad clinical experience in a hospital setting or case management.
Demonstrate recent knowledge/experience within past 4 years in Discharge Planning and Utilization review.
Working knowledge of InterQual®, or equivalent system.
Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies.
Excellent organization and time management skills.
Ability to work independently and effectively in a fast pace environment.
Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
Proficient computer skills with ability to utilize and integrate updated software systems into practice.

Nice To Haves

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

Responsibilities

Screen new admissions daily for discharge planning needs.
Establish priority of visits based on screening criteria.
Verify accuracy of demographics and payer information and notify admissions of corrections.
Complete Initial Assessment in InterQual® for patients with identified needs within one (1) business day of identification.
Perform reassessments every three (3) days as needed for changes in medical status, diagnosis, or caregiver.
Review appropriateness of patient’s admission and level of care needs (Inpatient and Observation) utilizing InterQual® Criteria.
Follow policy and procedure if Level of Care is not met.
Initiate timely HINN Notices and letters of reinstatement.
Coordinate patient appeal rights under the Discharge Appeals program.
Identify patients and families who have high-risk complex psychosocial/financial and legal needs and refer patients to appropriate resources.
Responsible for utilization review on assigned unit.
Facilitate third party reimbursement by responding to third party payer requests for concurrent clinical information in support of ongoing services, turnaround time by day end.
Work closely with attending physician/interdisciplinary team to facilitate appropriate care and services.
Ensure that the interdisciplinary care plan and the discharge plan are consistent with the patient’s required needs and covered services.
Participate/facilitate in unit’s daily rounds.
Advocate for patients through the development of effective partnerships with patient families, payers and healthcare team.
Act as patient advocate communicating with patients/families regarding adverse determinations and other issues related to insurance coverage and ongoing care requirements.
Facilitate and maintain patient’s independence in decision making when appropriate.
Coordinate and communicate thorough and complete referral information to enhance a safe transfer of patient to other facilities or agencies.
Complete all necessary paperwork based on need and regulation.
Demonstrate knowledge of community resources and act as resource to staff in providing safe and effective post hospital care.
Participate and accurately apply approved standards of care/Care Maps and clinical pathways in evaluating and monitoring the patient’s clinical course.
Participate in the development and revision of pathways.
Participate in care conferences on patients across the continuum.
Evaluate continued length of stay of patients for appropriateness per recognized InterQual® criteria.
Make appropriate referrals to Physician Advisor if criteria is not met and resolution with the attending physician cannot be accomplished.
Identify days at risk for denial and initiate strategies to facilitate care and accomplish discharge.
Assist medical coders by obtaining necessary diagnostic and procedural information to assure appropriate reimbursement.
Maintain established departmental policies and procedures, objectives, quality assurance program, safety, environmental and Infection Control standards.
Maintain core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
Participate in education programs, in-services, and meetings as required.
Recognize/understand responsibility of this key role and the responsibility this position demands in direct support of high quality patient care delivery regardless of assignment.
Display flexibility, cooperation and characteristics of a team member.
Consistently provide service excellence to all patients, family members, visitors, volunteers and co-workers.
Performs other related duties as assigned or requested.