RN Case Manager
Company: South Shore Health
Location: Weymouth
Posted on: April 18, 2024
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Job Description:
Job Description Summary 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. Job Description 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 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
- - 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 measurements 12 -
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, Epic,
Workday JOB REQUIREMENTS Minimum Education - Preferred 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 RN - Registered Nurse Required
additional Knowledge, and Abilities 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 utilization management
as it relates to third party payers Knowledge of post-acute care
community resources Experience with Managed Care preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing
priorities and regulations.
Keywords: South Shore Health, Weymouth , RN Case Manager, Healthcare , Weymouth, Massachusetts
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