Case Management Nurse Job Cambridge area,Massachusetts USA,Nursing

RN License in the state of Massachusetts
3 years acute care experience within the past 5 years with broad clinical experience in a hospital setting or case management.
Working knowledge of Inter Qual®, or equivalent system
Demonstrate recent knowledge/experience within past 4 years in Discharge Planning and Utilization review - Dyad

JOB DESCRIPTION

Screen new admissions daily for discharge planning needs.
Establish priority of visits based on screening criteria.
Verify accuracy of demographics and payer information in and notify admissions of corrections.
Patients with identified needs for follow-up are seen within one (1) business day of identification and the Initial Assessment is completed in Inter Qual®.
Reassessments are done every three (3) days as needed for changes in medical status, diagnosis, or caregiver.
Review appropriateness of patient’s admission and level of care needs (Inpatient and Observation) utilizing Inter Qual® Criteria. Follow policy and procedure if Level of Care is not met.
Initiates timely HINN Notices and letters of reinstatement.
Coordinates patient appeal rights under the Discharge Appeals program.
Identifies patients and families who have high-risk complex psychosocial/financial and legal needs and refers patients to appropriate resources.
Responsible for utilization review on assigned unit.
Facilitates third party reimbursement by responding to third party payer requests for concurrent clinical information in support of ongoing services, turnaround time by day end.
Works closely with attending physician/interdisciplinary team to facilitate appropriate care and services.
Ensures that the interdisciplinary care plan and the discharge plan are consistent with the patient’s required needs and covered services.
Participate/facilitate in unit’s daily rounds.
Advocates for patients through the development of effective partnerships with patient families, payers and healthcare team.
Acts as patient advocate communicating with patients/families regarding adverse determinations and other issues related to insurance coverage and ongoing care requirements.