RN Clinical Coordinator, Case Management, 32-Hours, Days, No Weekends or Holidays

Athol Hospital•Athol, MA

1d•$38 - $57•Onsite

About The Position

Heywood Healthcare values its employees and offers competitive wages, great benefits, and generous earned time off. This 32-hour per week, day shift position with no weekends or holidays offers the opportunity to work where you will matter. The role involves utilization management, care transitions, coordination, discharge planning, and administrative oversight of the Swing Bed Program.

Requirements

Previous UR/QA experience required
Current Massachusetts Registered Nurse License
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.
Provides administrative and Swing Bed admission oversight responsibilities

Nice To Haves

BSN preferred
2 years of healthcare experience within the Acute Care, SNF, HHA, Behavioral Health and/or Insurance Industry preferred
Interqual experience or equivalent preferred
Meditech Expanse experience preferred
Leadership experience a plus

Responsibilities

Conduct utilization reviews and manage care transitions and coordination.
Provide clinical information to payers, monitor length of stay, seek care authorizations, and utilize the InterQual Program; appeal denials.
Review all new admissions and Observation patients within 24 hours of admission against High Risk Screening Criteria and document outcomes.
Follow up on lack of documentation for medical necessity and support documentation.
Track and trend opportunities for improvement related to late Insurance Reviews and longer lengths of stay; educate providers on Interqual Criteria.
Complete utilization reviews daily or as required by insurer for medical and/or psychiatric appropriateness.
Assess, intervene, evaluate, and determine the level of care to establish accurate admission and/or observation status.
Demonstrate clinical expertise in issuing ABN/HINN notices and managing care progression, keeping physicians and teams informed.
Provide education and information to patients, families, and care providers regarding continuing care, care management, LOS, and re-hospitalization.
Participate in discharge planning rounds daily.
Collaborate with a multidisciplinary team to determine patient needs, address LOS issues, and identify potential needs and resources.
Review medical records for abnormal findings, complications, delays, and deviations from expected clinical outcomes.
Acquire knowledge of changes in technology and regulations, and utilize this knowledge to redesign systems for improving performance.
Continuously prioritize projects, activities, and tasks to ensure deadlines and customer needs are met.
Assist with the preparation of reports and statistics related to staff-specific workflow.
Complete assessment of denials within 1 week, providing supporting documentation and documenting interventions.
Prepare written appeal letters, termination letters, discharge notices, MOON, and IMs as per regulatory standards and department policies.
Report any variances and trends to the director.
Submit denials/appeals to the department secretary for processing.
Build rapport and respond to the needs of physicians, managed care plan reviewers, healthcare team members, third-party payers, outside reviewers, and vendors.
Complete nursing sections of SNF Level of Care forms for Mass Health patients and other forms assisting in transition of care, collaborating with the social worker.
Complete discharge planning assessments timely, efficiently, and completely.
Appropriately level patients for home discharge or to another type of facility.
Develop, coordinate, and implement discharge plans with patients and/or their families/caregivers, identifying patient preferences.
Notify providers, establish and determine anticipated readiness for discharge, and keep patients/families informed.
Close out cases using appropriate forms for transition of care communication.
Assist the Multidisciplinary Team in providing discharge planning activities to expedite patient discharge.
Remain current and proficient in the discharge planning process to provide coverage when needed.
Cover referrals from the Emergency Department for discharge planning & HRSN information & referral services.
Develop a standardized process for screening Swing Bed Program referrals.
Work closely with referral sources to maintain positive working relationships and market the Swing Bed Program.
Maintain current education and knowledge of payment sources and admission regulations.
Work closely with the Rev Cycle Team to obtain Single Case Agreements and verify SNF benefit coverage.
Confer with the Admission Team, Nursing Manager or designee, and Provider on referral acceptance or denial decisions.
Complete admission paperwork within established timeframes.
Keep abreast of department policies and procedures for Critical Assess, Acute Care, and Swing Bed regulatory requirements.
Plan and coordinate three community marketing programs annually for outreach & referrals.
Responsible for Swing Bed Performance Improvement Activities.
Maintain Department data for each fiscal year on metrics using both the Care Management Module and BCA reporting.
Perform any other duties as assigned by the director and/or designee.