Case Manager - Social Services

Berkshire Health Systems; North Adams (MA); On-site; USD 85,000 - 105,000; Full time

Job summary

Berkshire Medical Center is seeking a Case Manager to oversee admission, discharge planning and transition care, coordinating services across the continuum for optimal outcomes and cost containment.

The role requires robust clinical experience in acute care and familiarity with utilization management, CMS regulations, and evidence-based criteria tools. Strong communication and data-analysis skills are essential to support quality patient care.

Qualifications

• Three years clinical experience in acute care in areas such as internal medicine, surgery, orthopedics.
• Three years clinical experience in Rehab Setting, Home Health and Long-Term Care would be considered.
• Ability to perform a comprehensive admission and discharge risk assessment related to quality, financial, payer benefit allowances and limitations, risk management and patient satisfaction.
• Case Management experience required for weekend, temporary and per diem positions.
• Current knowledge of CMS (levels of care determinations), appeal rights & DPH regulations required.
• Current knowledge of Ma Pro QIO (appeals) required

Responsibilities

• Manage admission and discharge planning and transition care for patients.
• Coordinate and monitor services across the continuum of care.
• Collaborate with multidisciplinary team to ensure appropriate level of care and resource utilization.
• Review patient care and negotiate with providers, patients, and payers as needed.

Skills

Case management experience

Utilization management

CMS level of care knowledge

Discharge planning

Regulatory knowledge

Data analysis

Education

Associate degree in Nursing

Bachelor's degree in Nursing

Job description

• The Case Manager is responsible for managing the healthcare needs, facilitation and achievement of quality and cost outcomes of all patients within Berkshire Medical Center, across the continuum. The case manager, utilizing a multidisciplinary team approach, negotiates, procures, coordinates and monitors services and resources needed by patients. The case manager is responsible for reviewing the patient at admission, and in some instances prior to admission, and concurrently throughout the hospital stay for the appropriate level of care and utilization of resources. The case manager will perform transition care planning activities to secure appropriate post hospital care arrangements and will monitor the patient during the course of their hospitalization. The case manager participates with the performance improvement initiatives undertaken by Berkshire Health Systems
• POSITION QUALIFICATIONS (Minimum qualifications are required unless stated otherwise.)
• Experience:
• Three years clinical experience in acute care in areas such as internal medicine, surgery, orthopedics, mother/child, cardiology, and oncology.
• Three years clinical experience in Rehab Setting, Home Health and Long-Term Care would be considered.
• Ability to perform a comprehensive admission and discharge risk assessment related to quality, financial, payer benefit allowances and limitations, risk management and patient satisfaction.
• Case Management experience required for weekend, temporary and per diem positions.
• Experience specializing in utilization management (levels of care knowledge and demonstrable competence with evidence-based criteria tools), discharge planning to entities throughout a continuum of care, previous care management or third-party insurance review required
• Current knowledge of CMS (levels of care determinations), appeal rights & DPH regulations required
• Current knowledge of Ma Pro QIO (appeals) required
• Knowledge of regulatory and accreditation organizations such as Joint Commission, DPH and HealthGrades preferred
• Education and Training:
• Associate degree is Nursing required.
• Bachelor’s Degree in Nursing within four years of hire.
• License, Certification & Registration:
• RN - Currently licensed as an RN in Massachusetts
• CPR
• CCMACM – Certified Case Manager or Accredited Case Manager within two years of hire
• RN-BC – Registered Nurse, Board Certification in Case Management with two years of hire
• Other Requirements:
• Organizational skills. Proven ability to analyze and present data. Computer literacy. Ability to plan, implements, and evaluate change.
• Proven excellent interpersonal and communication skills
• Ability to maintain confidentiality
• Proven collaboration & negotiation skills with providers, patients, families, insurance organizations and government agencies
• Proven ability to work independently
• Demonstrated ability to establish and maintain relationships with physicians
• Knowledge of local community resources required
• Knowledge of Medicare, Medicaid, third party commercial payers and reimbursement required
• Computer experience required with proven ability to manage multiple open applications
• Skills in data comprehension, research, analysis, interpretation, and judgement necessary to prepare a comprehensive summary report for files, management, legal and/or regulatory agencies upon request