RN Case Review Coordinator - Per Diem - Faulkner

Mass General Brigham•Boston, MA

3d•$41 - $100•Onsite

About The Position

The RN Case Review Coordinator is responsible for performing the six essential activities of Case Management: Assessment, Planning, Implementation, Coordination, Monitoring, and Reassessment throughout the continuum of care to facilitate a safe and cost-effective transition post-discharge. This role also performs all aspects of audits and appeals, including the peer-to-peer process. The position requires performing utilization reviews to evaluate the appropriate level of care and timely submission of insurance reviews to prevent denials. Collaboration with patients, families, and the interdisciplinary team is crucial for assessing discharge needs. The role involves placing and implementing referrals to post-acute care services, documenting interactions, and interacting with third-party payers daily. Cases not meeting the appropriate level of care are referred to the Physician Advisor or EHR. The coordinator reviews and makes changes to observation status as needed, accurately facilitating documentation for Medicare status changes. Quality issues are monitored and documented, and patients/representatives receive necessary notifications and acknowledgments regarding post-acute facilities or services. The role requires independent functioning in a busy environment and coordination, completion, and tracking of all clinical denials and appeals.

Requirements

BSN required.
Current Registration as a Licensed Nurse in the State of Massachusetts.
3 year of Utilization Review and Case Management experience required
5 years of Acute Care Nursing Required

Nice To Haves

4 or more years of Utilization Review and Case Management experience preferred
6 or more years of Acute Care Nursing preferred
CCM preferred.

Responsibilities

Perform utilization review to evaluate for appropriate level of care and faxes all insurance reviews timely to prevent denials.
Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs.
Place and implement all aspects of referrals to all levels of post acute care in 4 Next.
Online documentation of interaction with patient, family and interdisciplinary team.
Interact with various third party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
Refer cases not meeting appropriate level of care to the Physician Advisor or EHR.
Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change inpatient to observation (code 44).
Perform and monitor for quality issues and document in R.L. solutions.
Provide to the patient or family member a copy of the Important Message.
Provide to the patient or representative the Observation Notification letter.
Provide to the patient representative the Acknowledgement of disclosure ,obtain choices of post acute facilities or service and signature.
Coordinate, complete and track all clinical denials and appeals.