Case Management Nurse

Sturdy Health; Attleboro (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

Sturdy Health in Massachusetts seeks an RN ED Case Manager to coordinate patient transitions as part of an interdisciplinary team. You will assess pre-admission needs, plan safe and timely discharges, and ensure compliant documentation using the ED tracking system.

Responsibilities include collaborating with ED providers, reviewing admission status, arranging appropriate LOC and post-acute services, and communicating with patients and families to support optimal care transitions.

Qualifications

• Graduate of an accredited school of nursing; BSN/MSN preferred.
• Massachusetts RN license required.
• 3–5 years in acute care case management with utilization review.
• Strong communication and interpersonal skills; ability to work with diverse stakeholders across the care continuum.
• Solid knowledge of CMS/Medicaid regulations to ensure compliance with required processes and documentation.
• Proficient in using EHRs and tracking systems for patient status and care coordination.
• Ability to analyze patient data to determine level of care and discharge planning needs.

Responsibilities

• Identify admissions/alternative dispositions using ED tracking system and collaborate with ED providers.
• Screen ED patients for admission potential and appropriate payer source.
• Coordinate LOC designation and ensure medical record documentation.
• Conduct initial and ongoing reviews; communicate LOS concerns to case management.
• Refer to home health, rehab/SNF, or community resources as appropriate.
• Coordinate discharge planning with therapies, social work, and ancillary services.
• Document all coordination efforts and communicate with teams for follow-up.

Skills

Utilization review

Critical thinking

Discharge planning

Communication

Interdisciplinary collaboration

Documentation

Problem solving

CMS/Medicaid regulations

Independent work

Education

BSN/MSN preferred

Tools

Cerner

Job description

Working in collaboration with the patient/family/legal representative, social workers, physicians, and interdisciplinary team, the RN ED case manager is accountable for assessing, coordinating and facilitating patient progression through the continuum of care in an efficient, cost effective manner. The RN ED Case Manager must achieve this through early assessment of pre-admission level of care, post hospital discharge needs, review of available resource and timely, focused communication with the healthcare team and patient/family/legal representative.

Education/Training:

• Graduate of an accredited school of nursing: BSN/MSN preferred

Licenses/Certification:

RN with current Massachusetts license required

Required Qualifications and Skills:

• Minimum 3-5 years of experience in acute care case management, with demonstrated skills in utilization review
• Demonstrated ability to use critical thinking and problem solving skills in facilitating safe and timely patient transitions of care
• Excellent communication skills and positive interpersonal dynamic in working with a variety of stakeholders across the care continuum
• Solid knowledge of all insurance plan regulations including CMS/Medicaid to ensure compliance with all required processes and documentation
• Ability to garner and utilize information effectively to develop and modify patient plan of care
• Strong analytical ability to interpret patient-related information, evaluate appropriateness of continued stay and/or need for ancillary services, and to reassess discharge planning needs based on daily assessment.
• Ability to successfully utilize industry accepted utilization and or medical management criteria in patient status decision making
• Self-starter able to function independently within the scope of position and licensure, as well as department policies and established goals
• Excellent computer skills to accurately document requisite information to support patient status and medical necessity

Preferred Qualifications and Skills:

• Experience in Cerner a plus
• Denials management a plus

Essential Job Functions:

• Use ED tracking system, medical record, and on-going communication with ED providers and team to identify potential admissions or alternative disposition as appropriate.
• Screen all ED patients for potential for admission to ascertain payer source and appropriate level of care designation.
• Collaborate with providers to determine, assign, and order appropriate level of care (LOC) designation and ensure medical record documentation.
• Determination of appropriate admission status (observation vs. inpatient) using standardized criteria; providing resources and education to the healthcare team.
• Initiate and/or complete initial review
• Communicate LOC and/or length of stay (LOS) concerns to case management team for follow-up the next morning.
• Consults with and takes referrals from ED providers, nurses, hospitalists, other care team members, ED patients, and families.
• Reviews all consults placed from ISAR screening tool and assists social worker with completion of these consults in order to provide patients with needed home referrals or rehab/SNF placement.
• Responds to outside patient/family calls for follow-up care coordination questions.
• Uses ED tracking system, medical record, and demographic information to identify high-risk or any patient needing CM intervention.
• Identify patients with frequent ED visits utilizing the EHR and EDIE collective medical group notifications.
• Identify patient returning in 48 hours to ED or hospitalization within 30 days.
• Assess ED patients referred and/or identified through case finding for options other than acute hospital admission when appropriate:
• Screen and refer to acute rehabilitation, long-term acute care hospitals, and nursing homes for admission directly from the ED.
• Screen and refer patients for whom treatments could be safely rendered at home with services (i.e., IV antibiotics, low molecular weight heparin injections, wound care, etc.)
• Consult additional services to complete a safe and effective discharge plan, including physical therapy, social services, palliative care, interpreters, homeless advocates, patient financial services, behavioral health, etc.
• Communicate discharge planning information and/or concerns to team for follow-up the next morning.
• Initiate referral to long term care facilities, per patient/caregiver requests, following established referral procedures, initiates a PASRR screen, and ensures appropriate continuity of care information is provided to facility.
• Mandatory reporting to regulatory agencies
• Provide additional community resources and support

Other duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

AGE AND DIVERSITY RELATED CRITERIA

Consistently treats patients, colleagues and visitors with the dignity and respect, while being sensitive to the differing needs of all age groups, backgrounds, characteristics and cultures.

ABILITY TO FULFILL JOB EXPECTATIONS

Must have the ability to the perform essential functions of the position, including required work hours, locations and physical demands, without posing a direct threat to the health and safety of themselves or other individuals in the work place, and with or without reasonable accommodation.

PHYSICAL DEMANDS:

• Ability to sit (may be for long periods of time), stand, reach and lift up to 15 pounds
• Ability to readily travel to units/departments across the system as needed.
• Ability to communicate effectively with all stakeholders, in person as well as via telephone and electronically
• Ability to interact directly with patients, with potential for direct exposure to patient care activities
• Ability to document and use trackers, analyze charts and coordinate services within the electronic health record
• Ability to advocate for patients both internally and external to the system
• Ability to attend and participate professionally in meetings with Hospital leaders, physicians, patients and families