RN Case Manager Job Weymouth area,Massachusetts USA,Nursing

Overview

If you are an existing employee of South Shore Health then please apply through the internal career site.

Requisition Number: R-21824

Facility: LOC
0001 - 55 Fogg Road, 55 Fogg Road Weymouth, MA 02190

Department Name: SSH Care Progression

Status: Full time

Budgeted

Hours:

40

Shift: Day (United States of America)

The Case Manager provides patient advocacy, case management, discharge planning and care coordination under the supervision of the Case Management Manager. This on-site role coordinates, negotiates, procures services and resources for and manages the care of complex patients, aiming to achieve quality and cost-efficient outcomes. The role seeks opportunities to reduce cost while maintaining high quality of care, applies review criteria to determine medical necessity for admission and continued stay, and collaborates with interdisciplinary staff to optimize resource use across the continuum of care.

The Case Manager participates in quality improvement and evaluation processes related to patient care and is available on-site seven days a week, including weekends and holidays.

Compensation Pay Range: $ - $

Responsibilities

1 - The RN Case Manager is responsible for reviewing the medical records of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.

a - Using Inter Qual Criteria, physician certification, and payor-specific criteria, assist the physician in determining medical necessity for observation, admission and continued stays.

b - Identify cases daily that fail to meet criteria and refer these cases to the appropriate manager or physician advisor for secondary review.

c - Contact attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarify required clinical documentation to support medical necessity.

d - Contact attending physicians to notify them of a decision to issue notice of non-coverage, explain UR process and insurance coverage requirements, and obtain physician written concurrence when necessary (e.g., Medicare patients); inform patient/next of kin when insurance coverage must be terminated for the current admission; issue termination letter for Medicare patients.

e - Reinstates insurance coverage when patient condition becomes acute and meets criteria again; issue reinstatement letter.

f - Continue review of all patients using criteria to determine the need for continued hospitalization based on third party payor/insurance guidelines.

g - Provide clinical data to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and avoid delays within 24 hours of request.

h - Continue review of all patients using criteria and determine need for continued hospitalization based on third party payer/guidelines.

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

a - Identify and review observation patients to determine the correct patient level of care daily prior to 12 PM.

b - Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient; refer questionable status to internal physician advisor or EHR per departmental process.

c - Assume the role of review coordinator for observation services; review medical records for appropriateness of status and level of care, and facilitate the level of care using Inter Qual for Observation.

d - Work with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.

e - RN Case Manager to take telephone orders from physicians changing patient status from observation to inpatient admission; actively monitor and alert when inpatient status is indicated.

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

a - Identify potential transition planning problems to set up services required.

b - Work with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals; e.g., SNF/VNA/Home Pharmacy.

c - Identify need for new resources if gaps exist in the service continuum and initiate creative care delivery options.

4 - The RN Case Manager is responsible for assessing patient acute level of care needs and coordinating interventions to facilitate a safe and timely discharge plan to appropriate sub-acute settings in collaboration with the Case Manager Specialist.

a - Identify and prioritize workflow with patient-specific and unit-based needs.

b - Implement a safe and effective discharge plan per the Case Management assessment and Conditions of Participation.

c - Make and document appropriate changes to the discharge plan when necessary.

d - Proactively identify and overcome barriers to early/timely discharge.

e - Facilitate and coordinate patient care rounds.

f - Conduct necessary…


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