Case Management Rn Jobs

About The Position

Requirements

• Current Massachusetts Registered Nurse License Required
• Previous UR/QA experience required
• 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
• Proficient computer skills required
• 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.

Nice To Haves

• BSN preferred

Responsibilities

• Conducting utilization reviews and managing care transitions and coordination.
• Providing clinical information to payers, monitoring length of stay, and obtaining necessary care authorizations.
• Utilizing the InterQual Program and appealing denials in a timely manner.
• Reviewing all new admissions and Observation patients within 24 hours against High Risk Screening Criteria.
• Completing assessments on re-admissions within 30 days, documenting findings, and providing data for stratification.
• Following up on documentation for medical necessity and supporting documentation.
• Tracking and trending opportunities for improvement related to late Insurance Reviews and longer lengths of stay.
• Educating providers on Interqual Criteria for determining Admission or Observation status.
• Completing utilization reviews daily or as required by insurer for medical and/or psychiatric appropriateness.
• Assessing, intervening, evaluating, and determining the level of care to establish accurate admission and/or observation status.
• Demonstrating knowledge of DRG reimbursement and standardized measures for length of stay and acuity level status designation.
• Issuing ABN/HINN notices to patients and/or legal significant others and managing care progression.
• Keeping physicians and the team informed of status changes and documenting status.
• Providing education and information to patients, families, and care providers regarding continuing care, care management, LOS, and disease management.
• Participating in daily discharge planning rounds.
• Collaborating with the multidisciplinary team to determine patient needs, including post-acute care.
• Addressing LOS issues, appropriate patient leveling, potential needs, resources, and referrals for other disciplines.
• Reviewing medical records for abnormal findings, complications, delays, and deviations from expected clinical outcomes.
• Reporting findings to the Provider and/or Director to maintain efficient, cost-effective care episodes.
• Acquiring knowledge of changes in technology and regulations.
• Utilizing knowledge to redesign systems for improving performance.
• Prioritizing projects, activities, and tasks to meet deadlines and customer needs.
• Assisting with the preparation of reports and statistics related to staff workflow.
• Assessing denials within 1 week and providing supporting documentation.
• Documenting interventions in the UR EMR section.
• Preparing written appeal letters, termination letters, discharge notices, MOON, and IMs as per regulatory standards and department policies.
• Reporting variances and trends to the director.
• Submitting denials/appeals to the department secretary for processing.
• Building rapport and responding to the needs of physicians, managed care plan reviewers, healthcare team members, third-party payers, outside reviewers, and vendors.
• Completing nursing sections of SNF Level of Care forms for Mass Health patients.
• Collaborating with the social worker on forms assisting in transition of care.
• Completing discharge planning assessments timely, efficiently, and completely.
• Appropriately leveling patients for home discharge or transfer to other facilities.
• Developing, coordinating, and implementing discharge plans with patients and/or families/caregivers.
• Identifying patient preferences for HHA/SNF placements and ensuring patient preference forms are signed.
• Notifying providers of discharge plans and anticipated readiness for discharge.
• Keeping patients/families/significant others informed and documenting such in the EMR.
• Closing cases using appropriate forms for transition of care communication.
• Collaborating with the team to assist the Multidisciplinary Team in discharge planning activities.
• Remaining current and proficient in the discharge planning process to provide coverage when needed.
• Performing any other duties as assigned by the director and/or designee.

Benefits

• competitive wages
• great benefits
• generous earned time off