RN Care Coordinator; Case Manager BWH Job Boston area,Massachusetts USA,Nursing

Position: RN Care Coordinator (Case Manager) BWH

General Summary

The RN Care Coordinator (RNCC) manages a caseload of patients and is responsible for ensuring care that supports desired clinical and financial outcomes. It has the skills and knowledge specific to the unique needs of assigned patients. Coordinating the care prescribed by an interdisciplinary team, the RNCC utilizes patient assessment, care guidelines, protocols, payer regulations, and response to therapies to assess the episode of illness from pre admission to post discharge.

The RNCC participates in the ongoing evaluation of practice patterns and systems and supports efforts to improve quality, cost, and satisfaction outcomes. It mobilizes resources to maximize efficiency of care delivery.

Principal Duties and Responsibilities Care Facilitation

Prior to or within 24‑48 hours of admission the RNCC, by interview of the patient/family, discussion with the physician team and/or attending MD and other team members, develops a provisional treatment program and tentative discharge date.

Reviews daily treatment plan with physicians, nurses and patient/families to insure interdisciplinary communication and coordination is occurring.

Participates with nursing staff and physicians in patient care rounds to contribute to plan of care and monitor and report patient progress.

Collaborates with other departments to expedite sequencing and scheduling of interventions, consults, treatments and ancillary services.

Provides for daily continuity with patients to assure patient needs related to discharge are met.

Incorporates knowledge of utilization management principles and payer contracts into patient plans of care and keeps physicians and nurses informed of implications.

Presents alternatives to inpatient stay to attending MD, team and patient/family based on assessed patient level of care and insurance benefits.

Seeks assistance and/or consultation from Care Coordination leadership with plans for outlier and potential or actual resource intensive patients.

Interacts with internal and external health care providers to facilitate patient care including post‑discharge services.

Contributes to the development, implementation and monitoring of practice guidelines.

Identifies attending, resident and nurse learning needs related to case management and works with service leaders to develop educational plan.

Discharge Planning

Assesses continuing care needs in conjunction with other caregivers.

Coordinates and schedules interdisciplinary meetings with the patient and family regarding discharge needs and plan as appropriate.

Assures patient education consistent with discharge plan has occurred.

Identifies service, treatment and funding options for post‑hospital care.

Promotes interdisciplinary patient/family communications and documentation that facilitate discharge planning, striving to finalize plans the day prior to discharge.

Performs patient/family follow‑up after discharge to monitor and support desired outcomes.

Initiates contact with home health agencies and extended care facilities to insure prompt and effective transition of care.

Utilization Management

Identifies patients who are likely to have unmet insurance and resource needs and communicates with and/or makes referrals to other members of the health care team and other appropriate departments.

Communicates as needed with third‑party payers regarding patient's progress with treatment plan.

Identifies need for and issues Medicare notices of non‑coverage, providing appropriate documentation of the process and communication to patient/family and other members of the health care team.

Utilizing industry accepted utilization and/or medical management criteria (Inter Qual) identifies, monitors and reports variances from established treatment plan, including appropriateness of admission, continued stay, delays in treatment and discharge plan.

Conducts documented utilization reviews to insurers or intermediaries.

Identifies SNF and AND days for Medicare and Medicaid patients.

Initiates actions concurrently to reduce and/or eliminate inappropriate hospital admissions and days, and system delays.

Works with payers and physicians to concurrently address level of care…