CASE MANAGER-1
Company: South Shore Health
Location: Weymouth
Posted on: May 28, 2023
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Job Description:
If you are an existing employee of South Shore Health then
please apply through the internal career site.Requisition
Number:R-9123Facility:LOC0001 - 55 Fogg Road55 Fogg RoadWeymouth,
MA 02190Department Name:Care ProgressionStatus: Part timeBudgeted
Hours: 20Shift: Day (United States of America)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 achievement
of quality and cost efficient patient outcomes. Looks for
opportunities to reduce cost while assuring the highest quality of
care is maintained. 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 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. The
Case Manager is on-site and available seven (7) days a week as well
as holidays and, therefore, is required to work a weekend rotation
and also an occasional holiday.1 - The RN Case Manager is
responsible for reviewing the medical record of all observation and
inpatient admissions and continued stays to ensure appropriate
utilization and delivery of care. a - Using Interqual Criteria,
physician certification, and payor specific criteria, assists the
physician in determining the medical necessity for observation,
admission and continued stays. b - Identifies cases daily that fail
to meet criteria and refers these cases to appropriate manager or
physician advisor for secondary review. c - 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 d - 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 forms 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 e - Reinstates insurance coverage when patient condition
becomes acute and meets criteria again. Issues reinstatement
letter. f - Continues review of all patients using criteria and
determines need for continued hospitalization based upon third
party payor/insurance guidelines. g - 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. h - Continues
review of all patients using criteria and determines need for
continued hospitalization based upon 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 - Identifies and
reviews observation patients to determine the correct patient level
of care daily prior to 12 PM. b - 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. c - 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 InterQual for Observation. d - Works with
physicians, nursing and staff, patients and families to arrange
prompt and safe discharge e - 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.3 - Participates in case finding and pre-admission
evaluation screening to assure reimbursement. a - Identifies
potential transition planning problems in a timely manner to set up
services required. b - 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 c - Identifies
need for new resources if gaps exist in service continuum, and
initiates creative care delivery options.4 - The RN Case Manager is
responsible for assessing patient acute level of care needs and
works to implement and coordinate interventions aimed at
facilitating a safe and timely discharge plan to the appropriate
sub-acute settings in collaboration with the Case Manager
Specialist. a - With the Case Manager, work to identify, and
prioritize workflow through identification of patient specific,
department needs and or unit based needs. b - Executes and
implements a safe and effective discharge plan based on the case
management assessment in accordance with the Conditions of
Participation. c - Makes and documents appropriate changes to
discharge plan when necessary. d - Proactively uncovers barriers to
early/timely discharge and overcomes them. e - Facilitates and
coordinates patient care rounds. f - Conducts necessary conferences
and team meetings regarding specific patient needs. g - Implements
interventions that lead to patient accomplishing goals established
in Plan. h - Coordinates the necessary resources to accomplish
goals developed in Plan. i - Proactively affects system to
facilitate efficient flow of care, anticipates discharge process. j
- Gathers information from multidisciplinary team and monitors
appropriate discharge plan.5 - Continued. a - Uses and Updates the
interdisciplinary patient White Board for communication
enhancement; including RN Case Manager name, time/date/plan for
discharge. b - Issues the Medicare Important Message (IM). c -
Proper use of the Medical Necessity form for post discharge
transportation. d - Use of technical tools, i.e., eDischarge, EHR,
Interqual, MCCM e - Identifies and / or facilitates establishment
of a patient''s Health Care Proxy.p) f - Identifies patient Care
Plan Partner. g - Fosters patient and family awareness of Patient
Portal.6 - Ensure that patient has received all information related
to choice of follow-up care facilities according to patient and
family preference and any ACO preferred contracted providers. a -
Ensure that, at minimum, 3 referrals are processed for continuum of
care providers b - Document choices provided, with special
consideration of ACO relationships and preferences; and selections
made by patient and/or family in medical record. c - Expedite and
process referrals, in a timely manner to department standards,
including requesting and tracking screenings and acceptances of
patients by care providers, expediting responses from provider
facility personnel as necessary. d - Document response by
providers. e - Delivers the Medicare Important Message (IM) per
department protocol. f - Have patient, family/healthcare Proxy sign
discharge plan.7 - Interacts, communicates, and intervenes with
multi-disciplinary healthcare team in a purposeful, goal-directed
fashion. Works pro-actively and utilizes critical thinking skills
to maximize the effectiveness of resource utilization. Anticipates,
initiates, and facilitates problem resolution around issues of
resource use and continued hospitalization, discharge planning. a -
Establishes a means of communicating and collaborating with
physicians, other team members, the patient''s payers, and
administrators. b - Explores strategies to reduce length of stay
and resource consumption within the care managed patient
populations, implements them and documents the results. c -
Communicates to appropriate members of healthcare team patients at
risk of losing insurance coverage via termination of benefits,
facilitates discharge plan d - Maintains a pro-active role to
ensure appropriate documentation concurrently to minimize
inefficient resource utilization and prevent loss of reimbursement
e - Reviews physician documentation and follows procedures to seek
clarification where indicated of that documentation relative to
diagnosis and comment on the patient''s clinical state. f -
Coordinate and participate in daily multidisciplinary patient care
rounds. g - Uses the SBAR method to communicate with MD, and peers
h - Acts as a clinical resource to support the Case Manager
Specialist in resource utilization and discharge planning the more
clinically complex or long length of stay patient.8 - Establishes
and maintains effective communication with all referral sources,
insurers, vendors and patient supplier systems.9 - Maintains
consistently a professional commitment to institutions and
department''s goals and objectives. Demonstrates flexibility to the
department''s needs in relation to floor and work schedule, and any
other internal and external demands on the department. Continually
shows commitment to the Department by extending self when need
arises.10 - Maintains an updated knowledge base of and references
resources outlining provider benefits for care choices, including
public, private, and governmental payers and established /
preferred ACO relations a - Maintains a working knowledge of the
requirements of the payers most frequently seen with the patient
population. b - Maintains a working knowledge of the resources
available in the community for patients/families. c - Maintains
current nursing licensure CEU credits, case management
certification CEU''s. d - Maintains Interqual Certification.11 - Is
responsible for department operational excellence, regarding safe
and effective discharge planning; assures department delivers
quality services in accordance with applicable policies, procedures
and professional standards. a - Manages all activities so that
quality services are provided in an efficient and effective manner.
b - Services provided meet all applicable regulatory requirements c
- Participates in departmental and organizational Quality
Improvement initiatives involving the Lean principles and TIM
WOODS. d - Maintains departmental productivity measurements. e -
Has an awareness of departmental productivity measurements
including LOS and utilization f - Follows department policies,
procedures, and standards of care that support operational
excellence and productivity measurements12 - Attains all agreed to
goals and objectives within specified time frames, as part of the
organization''s overall mission.13 - Technology - Embraces
technological solutions to work processes and practices. a -
eDischarge, EHR, Interqual, MCCM, Meditech, Lotus NotesESSENTIAL
FUNCTIONS (Cont.)1 - Technology and Learning a - Participates in
continued learning and possess a willingness and ability to learn
and utilize new technology and procedures that continue to develop
in their role and throughout the organization. b - Embraces
technological advances that allow us to communicate information
effectively and efficiently based on role.JOB REQUIREMENTSMinimum
Education - PreferredRegistered Nurse, Bachelors prepared strongly
preferredMinimum Work Experience3-5 years acute care hospital
experience preferredCritical Care or Emergency Department
experience highly desirableRequired Licenses / Registrations RN -
Registered NurseRequired additional Knowledge, and
AbilitiesDemonstrated skills in the areas of: negotiation,
communication (verbal and written), conflict, interdisciplinary
collaboration, management, creative problem solving, and critical
thinking, time management and ability to multitask in high stress
environment.Knowledge of: healthcare financing, community and
organizational resources, patient care processes, and data
analysis.Knowledge of utilization management as it relates to third
party payersKnowledge of post-acute care community
resourcesExperience with Managed Care preferred.Excellent verbal
and written communication skills required.Demonstrates flexibility
via an ability to adapt to changing priorities and
regulations.8-430 5 days per pay period with weekend rotation every
4 weeks and occasional Holiday.Responsibilities if
Required:Education if Required: License/Registration/Certification
Requirements:Registered Nurse - Board of Registration in Nursing
(Massachusetts)
Keywords: South Shore Health, Weymouth , CASE MANAGER-1, Executive , Weymouth, Massachusetts
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