Case Manager

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

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)

Compensation Pay Range: $ - $

• Using Interqual 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 the necessary clinical documentation required to help support medical necessity.
• Contacts the attending physician to notify them 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 the patient’s condition becomes acute and meets criteria again. Issues the 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 the patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.

• 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 the questionable status to internal physician advisor or EHR according to the Departmental Process.
• Assumes the role of 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 must take telephone orders from physicians changing patient status from observation to inpatient admission. This should be done when monitoring observation status. A call or page should be made to physician if the RN Case Manager believes that this should be an inpatient admission and not wait until the 24 hours are ending before conversion. RN Case Manager must actively monitor patients on observation status and seek to clarify their status as close to the 24‑hour benchmark as possible.
  
  The RN Case Manager must send a concern in a timely fashion to facilitate the patient being put into the correct patient status and to provide timely notification.

• 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.

• With the Case Manager, work to identify, and prioritize workflow through identification of patient‑specific, department needs and/or unit‑based needs.
• Executes and implements a safe and effective discharge plan based on the case‑management assessment in accordance with the Conditions of Participation.
• Makes and documents appropriate changes to discharge plan when necessary.
• Proactively uncovers barriers to early/timely discharge and overcomes them.
• Facilitates and coordinates patient care rounds.
• Conducts necessary conferences and team…