RN Case Manager
About The Position
Under the general supervision of the Case Management Manager, the RN Case Manager acts as a patient advocate and case manager for South Shore Health and Emergency Center clients. This autonomous role coordinates and obtains services and resources for complex patients, manages care, and supports quality, cost-efficient patient outcomes. The role applies review criteria to determine medical necessity for admission and continued stays, provides clinically based case management, discharge planning, and care coordination, and promotes appropriate resource use across the continuum of care. The RN Case Manager works collaboratively with internal and external interdisciplinary staff and participates in quality improvement and patient-care evaluation processes. The RN Case Manager reviews observation and inpatient admissions and continued stays, helps determine appropriate patient status and level of care, coordinates with physicians and payers, and supports timely reimbursement. The role identifies transition-planning needs, develops and coordinates safe, timely discharge plans, arranges referrals and post-acute services, and addresses barriers to discharge. It communicates with patients, families, healthcare teams, insurers, referral sources, and community providers, and maintains knowledge of payer requirements and available resources. The position is on-site and available seven days a week, including holidays. The schedule is Monday through Friday on day shift, with a weekend rotation and occasional holiday work. The role reports to the Case Management Manager.
Requirements
- Registered Nurse (RN) license.
- Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification within two years of hire.
- Demonstrated negotiation, verbal and written communication, conflict resolution, interdisciplinary collaboration, management, creative problem-solving, and critical-thinking skills.
- Strong time-management and multitasking abilities in a high-stress environment.
- Knowledge of healthcare financing, community and organizational resources, patient-care processes, data analysis, utilization management, and post-acute care resources.
- Excellent verbal and written communication skills.
- Ability to adapt to changing priorities and regulations.
- Ability to work Monday through Friday on day shift and participate in weekend and holiday coverage.
Nice To Haves
- Bachelor’s-prepared Registered Nurse strongly preferred.
- Three to five years of acute-care hospital experience preferred.
- Critical Care or Emergency Department experience highly desirable.
- Experience with Managed Care preferred.
Responsibilities
- Review medical records for observation and inpatient admissions and continued stays to assess appropriate utilization and delivery of care.
- Apply InterQual, physician certification, and payer-specific criteria to support determinations of medical necessity and patient status.
- Identify cases that do not meet criteria and refer them for secondary review; seek clarification of clinical documentation from attending physicians.
- Communicate coverage decisions and requirements to physicians, patients, and families; issue applicable non-coverage and reinstatement notices.
- Provide clinical information to third-party payers to support continued reimbursement and prevent delays.
- Review observation patients daily, coordinate status and level-of-care decisions, monitor patients near the 24-hour benchmark, and facilitate appropriate status changes.
- Identify transition-planning problems and coordinate services, referrals, and resources, including post-acute care.
- Assess acute level-of-care needs and implement safe, effective, and timely discharge plans in collaboration with the Case Manager Specialist.
- Identify and address barriers to discharge, coordinate patient-care rounds and team meetings, and gather multidisciplinary input to monitor discharge plans.
- Use and update the interdisciplinary patient White Board and complete applicable discharge-planning documentation, including the Medicare Important Message and medical-necessity forms for post-discharge transportation.
- Facilitate establishment of a Health Care Proxy, identify the patient’s Care Plan Partner, and promote patient and family awareness of the Patient Portal.
- Explain follow-up care facility choices, process and track referrals, document patient and family choices and provider responses, and obtain signatures on discharge plans.
- Collaborate with physicians, interdisciplinary teams, payers, administrators, referral sources, insurers, vendors, and suppliers to resolve resource-use and discharge-planning issues.
- Use strategies to reduce length of stay and resource consumption, document results, and help prevent loss of reimbursement through timely and appropriate documentation.
- Act as a clinical resource to the Case Manager Specialist for clinically complex or long-length-of-stay patients.
- Maintain knowledge of payer benefits, payer requirements, community resources, and preferred ACO relationships; maintain required continuing education and InterQual certification.
- Support departmental operational excellence, productivity, regulatory compliance, quality improvement, and applicable policies and standards.
- Use relevant technology and systems, including eDischarge, EHR, InterQual, MCCM, Epic, and Workday.
- Meet agreed goals and objectives and adapt to changing departmental needs, priorities, regulations, and work schedules.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
