Case Manager
Listed on 2026-04-29
-
Nursing
Clinical Nurse Specialist, Nurse Practitioner, RN Nurse, Healthcare Nursing
Technology – Embraces technological solutions to work processes and practices.
- eDischarge
- EHR
- Interqual
- MCCM
- Epic
- Workday
Requisition Number: R-22541
Facility: LOC
0001 - 55 Fogg Road, Weymouth, MA 02190
Department Name: SSH Care Progression
Status: Full time
Budgeted
Hours:
40
Shift: Day (United States of America). Mon‑Fri 5‑8s or 4‑10s. Alternating weekends and holidays.
Under the general supervision of the Case Management Manager, the RN Case Manager acts as a patient advocate and case manager to SSH&EC clients. This autonomous role coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost‑efficient patient outcomes. The case manager looks for opportunities to reduce cost while assuring the highest quality of care is maintained.
The RN Case Manager applies review criteria to determine medical necessity for admission and continued stay, provides clinically‑based case management, discharge planning, and care coordination to facilitate the delivery of cost‑effective quality healthcare and assists in the identification of appropriate utilization of resources throughout the continuum of care. He/she 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, and is on‑site to ensure coverage daily including weekends and holidays.
Compensation Pay Range: $ – $
Responsibilities- Review the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
- Assist physicians in determining the medical necessity for observation, admission and continued stays using Interqual Criteria, physician certification, and payor specific criteria.
- Identify daily cases that fail to meet criteria and refer these cases to appropriate manager or physician advisor for secondary review.
- Contact attending physicians daily on cases that lack adequate documentation warranting acute hospitalization, clarifying the necessary clinical documentation required to help support medical necessity.
- Contact the attending physician to notify them of decision to issue notice of non‑coverage, explain the UR process and insurance coverage requirements, and obtain physician written concurrence when necessary (e.g., Medicare patients).
- Inform the patient and/or next of kin when insurance coverage must be terminated for the current admission and issue the termination letter for the Medicare patient.
- Re‑activate insurance coverage when patient condition becomes acute and meets criteria again; issue reinstatement letter.
- Continue review of all patients using criteria and determine the need for continued hospitalization based upon third‑party payor/insurance guidelines.
- Provide clinical data/information to contracted third‑party payers while patient is hospitalized to ensure continued reimbursement and to avoid delays within 24 hours of request.
Play an essential role in assisting physicians, nursing and staff with accurate determination of a patient’s observation status and preventing delayed discharges of observation patients.
- Identify and review observation patients to determine the correct patient level of care daily prior to 12 PM.
- Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient and refer questionable status to internal physician advisor or EHR according to departmental process.
- Assume the role of review coordinator for observation services; review medical record for appropriateness of status and level of care, and facilitate the level of care using Inter Qual for Observation.
- Work with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
- Take telephone orders from physicians changing patient status from observation to inpatient admission as needed, monitoring observation status and communicating promptly with physician.
Participate in case finding and pre‑admission evaluation screening to assure reimbursement.
- Identify potential transition planning problems…
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