RN Clinical Coordinator, Case Management, Per Diem, Days, Evenings, Weekends

Athol Hospital•Athol, MA

About The Position

You Matter Here! Heywood Healthcare values our employees! We offer competitive wages, great benefits and generous earned time off. Come work where you will matter! This role is responsible for Utilization Management, Utilization Review and Care Transitions & Coordination. It involves providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations, and utilizing the InterQual Program. The position also includes participating in Multidisciplinary Team Rounds & IDT Meetings, Quality & Statistical Data reviews, managing the Denials/Appeal Process, and overseeing Discharge Planning. Additionally, the role involves administrative oversight and process development for the Swing Bed Program.

Requirements

Current Massachusetts Registered Nurse License Required
Proficient computer skills required
Previous UR/QA experienced 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; leadership experience a plus.

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

Responsibilities

Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and utilizing the InterQual Program; appealing denials as indicated within a timely fashion.
Review all new admissions and Observation patients within 24 hours of admission against High Risk Screening Criteria and documents outcome within the UM EMR.
Follow-up on lack of documentation for medical necessity, supporting documentation with discipline identified.
Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay; including educating providers to Interqual Criteria used for determining Admission or Observation status.
Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for medical and/or psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
Assesses, intervenes, evaluates and determines level of care to establish accurate admission and/or observation status; demonstrates basic knowledge of DRG reimbursement, evidenced by standardized measures for length of stay and acuity level status designation.
Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression.
Keeping physician and team informed of status change and documenting status.
Provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.
Participates in discharge planning rounds daily.
Works collaboratively with a multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses potential needs, resources, referrals for other disciplines etc.
Reviews medical records for abnormal findings, complications, delays, and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost-effective episode of care for each patient and documents intervention provided.
Acquires knowledge to keep up with changes in technology and regulations.
Utilizes knowledge to redesign systems for improving performance.
Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
Assists with the preparation of reports/statistics as it pertains to staff-specific workflow.
Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
Report any variances, trends to director.
Submits denials/appeals when completed to the department secretary for processing.
Builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
Responsible for completing nursing sections of the SNF Level of Care forms for Mass Health patients in need of care, SNF placement, timely and efficiently and other forms assisting in transition of care as identified and collaborates with the social worker.
In the event of an emergency, Care Coordinator may complete the form in full and process it to help expedite discharge planning process and length of stay.
Completes discharge planning assessments timely, efficiently and completely following regulatory standards and departmental policies assuring appropriate patient flow.
Appropriately levels patient for home discharge with or without services or to another type of facility such as a SNF, Acute Rehab etc.
Develops coordinates and implements discharge plan on cases assigned with patient and/or family/so caregiver.
Identifying patient preference and selection choice for HHA/SNF placements having patient preference form checked off and signed/dates by patient and/or so.
When plan is in place, notify provider establish and determine anticipated readiness for discharge, keeping patient/family/so informed and documenting such in the EMR.
Closes case out using appropriate forms for transition of care communication timely and effectively.
Collaborates with the team to assist the Multidisciplinary Team in providing discharge planning activities to assist in expediting a patient’s discharge as part of the care transitions process.
Remains current and proficient in the discharge planning process in the event coverage is needed.
Covers referrals from the Emergency Department for discharge planning & HRSN information & referral services.
Develop standardized process for screening referrals for potential placement timely and efficiently.
Works closely with referral sources to maintain positive working relationship with both internal and external referral sources to market Swing Bed Program to ensure occupancy is at budgeted level.
Maintains current education and knowledge of payment sources and admission regulations.
Works closely with Rev Cycle Team including Director of Finance to obtain Single Case Agreements and verify current status of SNF benefit coverage prior to admission.
Confers with Admission Team, Nursing Manager or designee, and Provider (Hospitalist) on referral for acceptance or denial decision and notifies referral source timely & efficiently.
Completes admission paperwork within the established timeframes.
Keeps abreast of department policies and procedures for both Critical Assess, Acute Care, and Swing Bed regulatory requirements by TJC,CMS, DPH, DMA, etc to assure compliance to standards.
Plans and coordinates three community marketing programs annually for outreach & referrals.
Responsible for Swing Bed Performance Improvement Activities by referral and payment source; admissions, and discharges; monitors LOS; of referrals received rate of acceptance by source by admission or denial.
Maintains Department data for each fiscal year on metrics using both the Care Management Module and BCA reporting for both CM & Swing bed program.
Performs any and all other duties as assigned by director and/or designee.