Case Manager, Per Diem

UMass Memorial Health Care; Marlborough (MA); On-site; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated Case Manager to join their dynamic team. This role involves coordinating appeals, educating staff on compliance, and ensuring exceptional patient care. With a commitment to healing and community service, the organization fosters a collaborative environment where every team member plays a vital role. If you have a passion for patient advocacy and a strong background in case management, this opportunity offers the chance to make a significant impact in the healthcare field.

Qualifications

• 7-10 years of relevant experience in acute care case management.
• Expertise in care level criteria and InterQual standards.

Responsibilities

• Coordinate and submit appeals to third-party payers within deadlines.
• Educate staff on insurance documentation and compliance issues.

Skills

Utilization Review

Case Management

Communication Skills

Analytical Skills

Negotiation Skills

Technical Writing

Organizational Skills

Education

Bachelor's Degree

Current Massachusetts RN Licensure

Graduate of an Accredited Nursing School

Job description

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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. We focus on exceptional patient care, academic excellence, and leading-edge research. With over 16,000 employees, we are committed to healing our patients, community, and each other. Everyone plays an important part, every day.

I. Major Responsibilities

• Coordinate and submit appeals to third-party payers within deadlines to avoid penalties.
• Serve as the key contact for Medicare RAC denials, processing each denial following established protocols.
• Review medical records with Case Managers to gather documentation for appeals.
• Communicate with payers about disputed claims and document ongoing efforts.
• Draft, edit, and finalize appeal letters for submission.
• Collaborate with physicians, Patient Financial Services, Patient Access, and Medical Records to gather necessary information.
• Record denial activities daily in tracking software as responses are received.
• Use Physician Advisor resources to engage with physicians as needed.
• Maintain denial tracking with Finance, including levels in the appeals process, financial impact, and success rates.
• Generate quarterly reports analyzing denial trends for management.
• Assist in onboarding new staff regarding denial and appeals processes.
• Keep staff updated on payer policies and changes.
• Review observation and inpatient status determinations; serve as a resource for related queries.
• Educate staff and physicians on insurance documentation requirements.
• Monitor and provide feedback on documentation quality for patient conditions.
• Oversee audits related to utilization review and case management activities.
• Coordinate the Utilization Review Committee and ensure operational excellence.
• Develop departmental performance metrics, analyze outcomes, and implement improvements.
• Manage departmental staffing, productivity, and budget to meet standards and goals.
• Promote professional leadership and participate in hospital and community activities.
• Support hospital programs, projects, and interdepartmental initiatives.
• Handle patient complaints and follow up on Press Ganey feedback, focusing on service recovery.
• Provide coaching and training to staff on patient experience topics.
• Oversee utilization, quality, and discharge planning reviews, ensuring appropriate certifications and documentation.
• Assess patient care levels, collaborate with physicians on discharge planning, and utilize community resources.
• Use appeals to advocate for patients when necessary and provide discharge education.
• Manage case management scheduling, correspondence, and quality reporting.
• Participate in hospital committees and serve as secretary for the Utilization Review Committee.
• Conduct annual staff performance appraisals and identify educational needs.
• Perform other duties as assigned by CNO/COO.

Standard Management Level Responsibilities

• Supervise personnel, evaluate performance, and handle HR functions.
• Develop and manage budgets, ensuring financial goals are met.
• Assign tasks, resolve operational issues, and evaluate solutions.
• Provide leadership, foster teamwork, and promote a respectful environment.
• Ensure compliance with regulations and hospital policies.
• Maintain departmental equipment, supplies, and policies.
• Ensure safety and health regulations are followed.
• Maintain reliable attendance and perform related duties.

II. Position Qualifications

All responsibilities are essential.

Licensure/Certification/Education

• Current Massachusetts RN licensure.
• Graduate of an accredited nursing school.
• Bachelor’s degree required.

Experience/Skills

• 7-10 years relevant experience, including UR/Case Management in acute care.
• Expertise in care level criteria and InterQual standards.
• Proficiency in case management, including direct care planning.
• Knowledge of reimbursement models: Commercial, Managed Care, Medicare, Public Assistance.
• Excellent communication and negotiation skills.
• Ability to educate staff on utilization and compliance issues.
• Strong organizational, analytical, and computer skills.
• Technical writing skills for reports and appeals.
• Ability to prioritize and manage multiple tasks independently.

Preferred

• Case Management or Billing/Coding certification preferred.

Physical Demands and Environment

• Reaching, grasping, working indoors; hearing and vision requirements.
• Lifting/carrying 0-10 lbs frequently; 10-50 lbs occasionally.
• Standing, walking, bending, high-stress environment.
• Sitting, pushing, twisting as needed.

UMass Memorial Health is an equal opportunity employer. We value diversity and encourage applications from all qualified individuals. We are committed to a respectful workplace and provide accommodations for applicants with disabilities.