Case Manager, Per Diem

HAHHH; Marlborough (MA); On-site; USD 60,000 - 95,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated RN to join their team. This role involves coordinating appeals for third-party payers, ensuring compliance with regulations, and providing exceptional patient care. With a strong emphasis on teamwork and communication, you will be a vital part of a dynamic environment focused on improving healthcare outcomes. Candidates with a robust background in case management and a passion for patient advocacy will find this position both rewarding and impactful. Join a forward-thinking organization that values respect and excellence in patient care.

Benefits

Signing Bonus

Health Insurance

Retirement Plan

Paid Time Off

Continuing Education Opportunities

Qualifications

• Current Massachusetts RN licensure required.
• 7-10 years of experience in UR/Case management in acute care.

Responsibilities

• Coordinate and submit appeals to third-party payers.
• Maintain dialogue with payers about disputed claims.
• Generate quarterly reports on denial activity.

Skills

Interpersonal Communication

Negotiation Skills

Analytic Skills

Data Management

Computer Skills

Education

Bachelor of Science in Nursing

Graduate of an accredited school of nursing

Tools

Denial Tracking Software

InterQual Criteria

Job description

Are you an internal caregiver, student, or contingent worker/agency worker at UMass Memorial Health? CLICK HERE to apply through your Workday account.

Exemption Status: Exempt

Schedule Details: Monday through Friday, Weekends (Saturday and Sunday)

Scheduled Hours: 8am-4:30pm

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 0.01

Cost Center: 21000 - 4402 Case Management

This position may have a signing bonus available; a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence, and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve.

I. Major Responsibilities:

1. Maintains responsibility for the coordination and submission of appeals to third-party payers within allotted timeframes to prevent fiscal penalties.
2. Is the key contact person for all Medicare RAC denials and processes each denial following the established framework.
3. Meets with the Case Managers to review the medical record to gather missing supportive documentation to strengthen the appeals process.
4. Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
5. Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third-party payer.
6. Interfaces with physicians, Patient Financial Services, Patient Access, and Medical Records to obtain necessary information as needed to respond to denials.
7. Enters all denial activity into denial tracking software on a daily basis as third-party payer responses are received.
8. Utilizes Physician Advisor to interface with physicians as needed.
9. Jointly maintains with Finance tracking of denials, the level in the appeals process for each denial, and the financial impact of denial management outcomes.
10. Generates reports of denial activity on a quarterly basis with analysis of data and significant trends to the Manager for Case Management and Revenue Cycle Team.
11. Assists in the orientation of new staff regarding the denial and appeals process.
12. Maintains up-to-date information from payers and distributes changes to all staff and departments involved in the appeal/denial process.
13. Regularly reviews observation and inpatient status determinations and serves as a resource to case managers, coding, and financial services regarding this status.
14. Provides ongoing education regarding insurance requirements and appropriate documentation for case managers and physicians.
15. Monitors and provides feedback to case managers, clinical staff, and physicians regarding appropriate documentation for patient conditions.
16. Oversees relevant auditing and monitoring related to utilization review and case management activities.
17. Coordinates the monthly Utilization Review Committee in collaboration with the physician chair.
18. Ensures operational excellence within the department to provide support to others and quality service in accordance with applicable policies, procedures, and professional standards.
19. Assists in achieving effective fiscal management of the assigned departments’ operations to ensure proper utilization of financial and other resources.
20. Demonstrates professional leadership and involvement within the Hospital, the System, and in the community served to promote support of the Hospital.

II. Position Qualifications:

Licensure/Certification/Education:
Required:
1. Current Massachusetts licensure of RN
2. Graduate of an accredited school of nursing.
3. BS required

Experience/Skills:
Required:
1. Minimum 7-10 years relevant experience including UR/Case management in the acute care setting.
2. Expert working knowledge of all applicable level of care criteria applications-both written and electronic.
3. Expert in InterQual criteria-maintains level of expertise to be hospital-wide trainer.
4. Comprehensive proficiency in the case management role, including direct patient interaction and care planning.
5. Expert knowledge of current reimbursement models: Commercial, managed care, Medicare, Public Assistance.
6. Excellent interpersonal communication and negotiation skills with physicians, payers, and peers.
7. Ability to engage and educate colleagues regarding utilization, regulatory, and compliance issues.
8. Strong analytic, data management, and computer skills.

III. Physical Demands and Environmental Conditions:

Constantly:
- Reaching, grasping, working indoors
- Precise hearing, vision
- Lifting, carrying, pushing, pulling 0-10 pounds

Frequently:
- Standing, walking, bending, repetitive movements, high stress level
- Precise motor skills

Occasionally:
- Sitting, pushing, pulling, twisting, climbing
- Lifting, carrying, pushing, pulling 10-50 pounds

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community, and each other.