Case Manager, Per Diem

UMass Memorial Health; Marlborough (MA); On-site; USD 60,000 - 100,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Case Manager to enhance patient care and streamline the appeals process. This role requires expertise in InterQual criteria and a strong background in case management within an acute care setting. As a key player, you will coordinate appeals, collaborate with various departments, and provide essential education on insurance requirements. Join a supportive environment that values respect and diversity, offering the chance to make a meaningful impact in the lives of patients and the community. If you are passionate about healthcare and ready to take on a challenging yet rewarding role, this opportunity is for you.

Benefits

Signing bonus

Health benefits

Professional development opportunities

Qualifications

• Must have a current Massachusetts RN license and a BS in nursing.
• 7-10 years of experience in UR/Case management in acute care.

Responsibilities

• Coordinate and submit appeals to third-party payers to avoid penalties.
• Maintain communication with case managers and document denial activities.

Skills

InterQual criteria expertise

Analytical skills

Interpersonal communication

Organizational skills

Technical writing

Negotiation skills

Data management

Education

Bachelor of Science in Nursing

Graduate of an accredited nursing school

Tools

Denial tracking software

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, the financial impact of denial management outcomes, and successfully overturned decisions.
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. Under the direction of the CNO/COO, ensures operational excellence within the department to provide support to others and quality service in accordance with applicable policies, procedures, and professional standards.
19. Seeking appropriate counsel from Human Resources and/or Director/Senior Manager, responsible for effective human resource management to achieve consistent and fair treatment of all staff.
20. Assists in achieving effective fiscal management of the assigned departments’ operations to ensure proper utilization of financial and other resources.
21. Demonstrates professional leadership and involvement within the Hospital, the System, and in the community served to promote support of the Hospital.
22. Performs and/or oversees integrated and concurrent utilization, quality, and discharge planning reviews of all admissions.
23. Conducts and/or oversees ongoing assessments of each patient’s level of care and collaborates with physicians to facilitate appropriate discharge and or transfer.
24. Responsible for proper performance of Case Management process, consistent with professional standards, department policy, and procedures.

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.
3. Expert in InterQual criteria.
4. Comprehensive proficiency in the case management role, including direct patient interaction and care planning.
5. Expert knowledge of current reimbursement models.
6. Excellent interpersonal communication and negotiation skills.
7. Ability to engage and educate colleagues regarding utilization, regulatory, and compliance issues.
8. Ability to work independently with excellent organizational skills.
9. Strong analytic, data management, and computer skills.
10. Technical writing ability for appeal letters and reports.
11. Analytical abilities to aggregate and report findings.

Preferred:
1. Certification in Case Management, Billing/Coding preferred.

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. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at [e-mail].