RN Case Manager

South Shore Health•Weymouth, MA

10d•$117,707 - $170,768•Onsite

About The Position

Under the general supervision of the Case Management Manager, acts as a patient advocate/Case Manager to SSH&EC clients. This is an autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost-efficient patient outcomes. The role focuses on opportunities to reduce costs while maintaining the highest quality of care. It involves applying review criteria to determine medical necessity for admission and continued stay, providing clinically-based case management, discharge planning, and care coordination to facilitate cost-effective quality healthcare. The position also assists in identifying appropriate utilization of resources across the continuum of care and collaborates with interdisciplinary staff, both internal and external to the Organization. Participation in quality improvement and evaluation processes related to patient care management is also a key aspect. The Case Manager is on-site and available seven (7) days a week, including holidays, requiring work on a weekend rotation and occasional holidays.

Requirements

Registered Nurse
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
RN - Registered Nurse license
ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire.
Demonstrated skills in negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, and ability to multitask in a high-stress environment.
Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
Knowledge of utilization management as it relates to third party payers.
Knowledge of post-acute care community resources.
Experience with Managed Care preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.

Nice To Haves

Bachelors prepared strongly preferred

Responsibilities

Reviewing the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
Assisting the physician in determining the medical necessity for observation, admission and continued stays using Interqual Criteria, physician certification, and payor specific criteria.
Identifying cases daily that fail to meet criteria and referring these cases to appropriate manager or physician advisor for secondary review.
Contacting attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifying the necessary clinical documentation required to support medical necessity.
Contacting the attending physician to notify him/her of decision to issue notice of non-coverage, explaining the UR process and insurance coverage requirements, and obtaining physician written concurrence when necessary (e.g., Medicare patients).
Informing the patient and/or next of kin when insurance coverage must be terminated for the current admission and issuing the termination letter for Medicare patients.
Reinstating insurance coverage when patient condition becomes acute and meets criteria again, and issuing a reinstatement letter.
Continuing review of all patients using criteria and determining the need for continued hospitalization based upon third party payor/insurance guidelines.
Providing clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
Playing an essential role in assisting physicians, nursing and staff with accurate determination of a patient’s observation status, and preventing delayed discharges of observation patients.
Identifying and reviewing observation patients to determine the correct patient level of care daily prior to 12 PM.
Consulting with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of a patient, and referring questionable status to internal physician advisor or EHR.
Assuming the role of review coordinator for observation services, reviewing the medical record for appropriateness of status and level of care, and facilitating the level of care using InterQual for Observation.
Working with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
Taking telephone orders from physicians changing patient status from observation to inpatient admission, and actively monitoring patients on observation status to clarify their status as close to the 24-hour benchmark as possible.
Participating in case finding and pre-admission evaluation screening to assure reimbursement.
Identifying potential transition planning problems in a timely manner to set up required services.
Working with the attending physician to move patients through the SSH&EC system and set up appropriate services or referrals (e.g., SNF/VNA/Home Pharmacy).
Identifying the need for new resources if gaps exist in the service continuum and initiating creative care delivery options.
Assessing patient acute level of care needs and implementing and coordinating interventions aimed at facilitating a safe and timely discharge plan to the appropriate sub-acute settings in collaboration with the Case Manager Specialist.
Identifying and prioritizing workflow through identification of patient-specific, department needs and/or unit-based needs.
Executing and implementing a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
Making and documenting appropriate changes to the discharge plan when necessary.
Proactively uncovering and overcoming barriers to early/timely discharge.
Facilitating and coordinating patient care rounds.
Conducting necessary conferences and team meetings regarding specific patient needs.
Implementing interventions that lead to patients accomplishing goals established in the Plan.
Coordinating the necessary resources to accomplish goals developed in the Plan.
Proactively affecting the system to facilitate efficient flow of care and anticipating the discharge process.
Gathering information from the multidisciplinary team and monitoring the appropriate discharge plan.
Using and updating the interdisciplinary patient White Board for communication enhancement, including RN Case Manager name, time/date/plan for discharge.
Issuing the Medicare Important Message (IM).
Proper use of the Medical Necessity form for post-discharge transportation.
Utilizing technical tools such as eDischarge, EHR, Interqual, MCCM.
Identifying and/or facilitating the establishment of a patient’s Health Care Proxy.
Identifying the patient Care Plan Partner.
Fostering patient and family awareness of the Patient Portal.
Ensuring that the patient has received all information related to the choice of follow-up care facilities according to patient and family preference and any ACO preferred contracted providers.
Ensuring that, at minimum, 3 referrals are processed for continuum of care providers.
Documenting choices provided, with special consideration of ACO relationships and preferences, and selections made by the patient and/or family in the medical record.
Expediting and processing referrals in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, and expediting responses from provider facility personnel as necessary.
Documenting responses by providers.
Delivering the Medicare Important Message (IM) per department protocol.
Having the patient, family/healthcare Proxy sign the discharge plan.
Interacting, communicating, and intervening with the multi-disciplinary healthcare team in a purposeful, goal-directed fashion.
Working proactively and utilizing critical thinking skills to maximize the effectiveness of resource utilization.
Anticipating, initiating, and facilitating problem resolution around issues of resource use, continued hospitalization, and discharge planning.
Establishing a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
Exploring strategies to reduce length of stay and resource consumption within the care managed patient populations, implementing them and documenting the results.
Communicating to appropriate members of the healthcare team patients at risk of losing insurance coverage via termination of benefits and facilitating the discharge plan.
Maintaining a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
Reviewing physician documentation and following procedures to seek clarification where indicated of that documentation relative to diagnosis and comment on the patient’s clinical state.
Coordinating and participating in daily multidisciplinary patient care rounds.
Using the SBAR method to communicate with MD and peers.
Acting as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning for more clinically complex or long length of stay patients.
Establishing and maintaining effective communication with all referral sources, insurers, vendors, and patient supplier systems.
Maintaining a professional commitment to institutions and department’s goals and objectives.
Demonstrating flexibility to the department’s needs in relation to floor and work schedule, and any other internal and external demands on the department.
Continually showing commitment to the Department by extending self when need arises.
Maintaining an updated knowledge base of and referencing resources outlining provider benefits for care choices, including public, private, and governmental payers and established/preferred ACO relations.
Maintaining a working knowledge of the requirements of the payers most frequently seen with the patient population.
Maintaining a working knowledge of the resources available in the community for patients/families.
Maintaining current nursing licensure CEU credits and case management certification CEU's.
Maintaining Interqual Certification.
Ensuring department operational excellence regarding safe and effective discharge planning; assuring the department delivers quality services in accordance with applicable policies, procedures, and professional standards.
Managing all activities so that quality services are provided in an efficient and effective manner.
Ensuring services provided meet all applicable regulatory requirements.
Participating in departmental and organizational Quality Improvement initiatives involving Lean principles and TIM WOODS.
Maintaining departmental productivity measurements.
Having an awareness of departmental productivity measurements including LOS and utilization.
Following department policies, procedures, and standards of care that support operational excellence and productivity measurements.
Attaining all agreed-to goals and objectives within specified time frames, as part of the organization’s overall mission.
Embracing technological solutions to work processes and practices, including eDischarge, EHR, Interqual, MCCM, Epic, Workday.