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Registered Nurse (RN) Care Coordinator Quality Medical Management

Company: South Shore Health
Location: Weymouth
Posted on: April 3, 2024

Job Description:

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.
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
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.
2 - Plays an essential role in assisting physicians, nursing and staff with accurate determination of a patient's observation status. 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. 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. 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.
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.
c - Makes and documents appropriate changes to discharge plan when necessary.
e - Facilitates and coordinates patient care rounds.
i - Proactively affects system to facilitate efficient flow of care, anticipates discharge process.
c - Proper use of the Medical Necessity form for post discharge transportation.
e - Identifies and / or facilitates establishment of a patient's Health Care Proxy.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.
Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization, discharge planning.
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
f - Coordinate and participate in daily multidisciplinary patient care rounds.
Demonstrates flexibility to the department's needs in relation to floor and work schedule, and any other internal and external demands on the department. 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
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.
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.
f - Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements

a - eDischarge, EHR, Interqual, MCCM, Epic, Workday

Registered Nurse, Bachelors prepared strongly preferred
Minimum Work Experience
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
Required Licenses / Registrations
Demonstrated 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 post-acute care community resources
Experience with Managed Care preferred.

Keywords: South Shore Health, Weymouth , Registered Nurse (RN) Care Coordinator Quality Medical Management, Executive , Weymouth, Massachusetts

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