RN Care Coordinator, Case Management, Per Diem, Days, Weekends

Heywood Hospital•Gardner, MA

3d•Onsite

About The Position

Heywood Healthcare values its employees and offers competitive wages, great benefits, and generous earned time off. This Per Diem, Days, Weekends position is for an RN Care Coordinator in Case Management. We are committed to equitable and transparent compensation practices, with the final compensation determined by relevant experience, skills, qualifications, and internal equity. The role involves significant patient interaction, care coordination, and collaboration with healthcare teams and payers.

Requirements

Current Massachusetts Registered Nurse License Required
Previous UR/QA experience required
2 years of healthcare experience within the Acute Care, SNF, HHA, Behavioral Health and/or Insurance Industry preferred
Proficient computer skills required
Must have effective written, verbal and interpersonal communication skills
Excellent critical thinking
Ability to multitask and flexibility essential
Discharge planning experience as it pertains to the care transitions, referral process, patient preference/choice services, patient & family satisfaction, post discharge follow-up etc.

Nice To Haves

BSN preferred
Interqual experience or equivalent preferred
Meditech Expanse experience preferred

Responsibilities

Conducting utilization reviews and managing care transitions and coordination.
Providing clinical information to payers, monitoring length of stay, and seeking necessary care authorizations.
Appealing denials in a timely fashion.
Reviewing new admissions and observation patients against High Risk Screening Criteria within 24 hours.
Completing assessments on re-admissions within 30 days, documenting findings, and providing data for stratification.
Following up on lack of documentation for medical necessity and supporting documentation.
Tracking and trending opportunities for improvement related to late insurance reviews and longer lengths of stay.
Educating providers on Interqual Criteria for determining admission or observation status.
Completing utilization reviews daily or as required by insurer for medical and/or psychiatric appropriateness.
Assessing, intervening, evaluating, and determining the level of care to establish accurate admission and/or observation status.
Demonstrating basic knowledge of DRG reimbursement.
Issuing ABN/HINN notices to patients and/or legal significant others and managing care progression.
Keeping physicians and teams informed of status changes and documenting status.
Providing education and information to patients, families, and care providers regarding continuing care, care management, LOS, and disease management.
Participating in daily discharge planning rounds.
Collaborating with the multidisciplinary team to determine patient needs, including post-acute care.
Addressing LOS issues, appropriate patient leveling, potential needs, resources, and referrals for other disciplines.
Reviewing medical records for abnormal findings, complications, delays, and deviations from expected clinical outcomes.
Reporting findings to the Provider and/or Director to maintain efficient, cost-effective care.
Acquiring knowledge of changes in technology and regulations.
Utilizing knowledge to redesign systems for improving performance.
Prioritizing projects, activities, and tasks to meet deadlines and customer needs.
Assisting with the preparation of reports and statistics related to staff workflow.
Assessing denials within 1 week and providing supporting documentation.
Preparing written appeal letters, termination letters, discharge notices, MOON, and IMs as per regulatory standards and department policies.
Reporting variances and trends to the director.
Submitting denials/appeals for processing.
Building rapport and responding to the needs of physicians, managed care plan reviewers, healthcare team members, third-party payers, outside reviewers, and vendors.
Completing nursing sections of SNF Level of Care forms for Mass Health patients.
Collaborating with the social worker on discharge planning forms.
Completing discharge planning assessments timely, efficiently, and completely.
Appropriately leveling patients for home discharge or transfer to other facilities.
Developing, coordinating, and implementing discharge plans with patients and/or families/caregivers.
Identifying patient preferences and choices for HHA/SNF placements.
Notifying providers and determining anticipated readiness for discharge.
Closing cases using appropriate forms for transition of care communication.
Assisting the Multidisciplinary Team in discharge planning activities to expedite patient discharge.
Remaining current and proficient in the discharge planning process.
Performing any other duties as assigned by the director and/or designee.