RN Case Review Coordinator - Faulkner

Mass General Brigham•Jamaica Plain, MA

6d•Onsite

About The Position

This full-time, 40-hour position performs the six essential activities of Case Management: Assessment, Planning, Implementation, Coordination, Monitoring, and Reassessment through the continuum of care to facilitate a safe, cost-effective transition post discharge. The role also performs all aspects of audits and appeals, including the peer-to-peer process. Responsibilities include performing utilization review to evaluate for appropriate level of care and timely submission of insurance reviews to prevent denials. The coordinator collaborates with patients/families and the interdisciplinary team to assess discharge needs, places and implements referrals to post-acute care services, and documents interactions. Daily interaction with third-party payers is required, including faxing clinical information to the correct insurer within the specified timeframe. Cases not meeting the appropriate level of care are referred to the Physician Advisor or EHR. The role involves reviewing and facilitating documentation for Medicare status changes (inpatient to observation, code 44), monitoring for quality issues, and documenting them. Additionally, the coordinator provides patients/families with necessary documentation such as the Important Message, Observation Notification letter, and Acknowledgement of Disclosure, and obtains choices of post-acute facilities or services and signatures. The position requires the ability to function independently in a busy environment and to coordinate, complete, and track 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.