RN Case Manager/per-diem Job Scituate area,Massachusetts USA,Nursing

Position: RN Case Manager / per-diem

Overview

Under the general supervision of the Case Management Manager, acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate quality and cost-efficient outcomes. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning, and care coordination to facilitate cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care.

Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care.

* Commits to working a minimum of 32 hours, with at least 16 hours (in 2 shifts) worked during a night and/or weekend per 4 week schedule. Also works 1 major summer or winter holiday.

Responsibilities

The RN Case Manager reviews the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.

Using Inter Qual Criteria, physician certification, and payor-specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
Identifies cases daily that fail to meet criteria and refers these cases to appropriate manager or physician advisor for secondary review.
Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity.
Contacts the attending physician to notify him/her of decision to issue notice of non-coverage. Explains UR process and insurance coverage requirements. Obtains physician written concurrence when necessary (e.g., Medicare patients).
Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission. Issues the termination letter for the Medicare patient.
Reinstates insurance coverage when patient condition becomes acute and meets criteria again. Issues reinstatement letter.
Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payor/insurance guidelines.
Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/guidelines.

Plays an essential role in assisting physicians, nursing, and staff with accurate determination of a patient’s observation status. The RN Case Manager is a resource in preventing delayed discharges of observation patients.

Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient; refers questionable status to internal physician advisor or EHR according to departmental process.
Acts as review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the level of care utilizing Inter Qual for Observation.
Works with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
RN Case Manager may take telephone orders from physicians changing patient status from observation to inpatient admission, with timely follow-up to ensure appropriate status.

Participates in case finding and pre-admission evaluation screening to assure reimbursement.

Identifies potential transition planning problems in a timely manner to set up services required.
Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals (e.g., SNF/VNA/Home Pharmacy).
Identifies need for new resources if gaps exist in service continuum, and initiates creative care delivery options.

Assesses patient acute level of care needs and coordinates interventions to facilitate a safe and timely discharge plan to appropriate sub-acute settings in collaboration with the Case Manager Specialist.

Identifies and prioritizes workflow with patient-specific or unit-based needs.
Executes and implements a safe and effective discharge plan per the case management assessment and applicable Conditions of Participation.
Makes and documents appropriate changes to discharge plan as needed.
Proactively uncovers barriers to early/timely discharge and overcomes them.
Facilitates and coordinates patient care rounds and necessary conferences and team meetings regarding patient needs.
Implements interventions that help patients accomplish goals in the Plan and coordinates resources to…

RN Case Manager​/per-diem

RN Case Manager/per-diem