Case Manager

Cape Cod Healthcare•Hyannis, MA

11d

About The Position

The Case Manager supports high-quality patient care through discharge planning, utilization review, coordination of care, and patient advocacy. The role screens new admissions for discharge planning needs, assesses and reassesses patients as appropriate, evaluates admission and level-of-care criteria using InterQual® or an equivalent system, and follows applicable procedures when criteria are not met. The Case Manager coordinates appeals, payer communications, referrals, safe transfers, and reimbursement-related documentation while working with patients, families, physicians, and the interdisciplinary team. The position also contributes to care planning, clinical pathways, quality and safety standards, and departmental education.

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 within the past four years in discharge planning and utilization review.
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 organizational 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 the 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 and prioritize visits based on screening criteria.
Verify demographic and payer information and notify admissions of corrections.
See patients identified as needing follow-up within one business day and complete the Initial Assessment in InterQual®; conduct reassessments every three days as needed when medical status, diagnosis, or caregiver circumstances change.
Review appropriateness of admission and level of care for inpatient and observation patients 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 for the assigned unit and respond to third-party payer requests for concurrent clinical information by the end of the day.
Work with attending physicians and the interdisciplinary team to facilitate appropriate care and services, and ensure care and discharge plans align with patient needs and covered services.
Participate in or facilitate daily unit rounds and care conferences across the continuum.
Advocate for patients by developing effective partnerships with families, payers, and the healthcare team; communicate adverse determinations and coverage or ongoing-care issues to patients and families.
Support patients’ independence in decision-making when appropriate.
Coordinate and communicate complete referral information to support safe transfers to other facilities or agencies, and complete required paperwork based on need and regulation.
Apply approved standards of care, Care Maps, and clinical pathways when evaluating and monitoring patients; participate in pathway development and revision.
Evaluate continued length of stay using recognized InterQual® criteria; refer cases to the Physician Advisor when criteria are not met and resolution with the attending physician cannot be achieved.
Identify days at risk for denial and initiate strategies to facilitate care and discharge.
Assist medical coders in 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.
Perform daily duties with accountability and initiative in support of high-quality patient care; work independently, comply with dress-code policies, and perform other related duties as assigned or requested.
Demonstrate flexibility, cooperation, and teamwork, and provide service excellence consistent with Cape Cod Hospital’s CARES commitment.