RN Case Manager

southshorehealth; Weymouth (MA); On-site; USD 118,000 - 171,000; Full time

Job summary

South Shore Health in Weymouth, MA is seeking an RN Case Manager to coordinate, negotiate, procure services, and manage the care of complex patients to achieve quality and cost-effective outcomes. Under supervision, you will review observation and inpatient records using criteria such as InterQual to determine medical necessity for admission and continued stay, and to guide discharge planning.

This on-site role requires collaboration with physicians, nursing staff, and payors, with weekend

Qualifications

• RN with hospital case management experience.
• Experience using InterQual criteria for admission decisions.
• Strong discharge planning and care coordination skills.

Responsibilities

• Review observation and inpatient records to determine medical necessity for admission and continued stay.
• Communicate with physicians regarding documentation and status changes.
• Notify payors and arrange continuity of coverage for transitions.
• Assist in discharge planning and care coordination across care settings.
• Monitor and facilitate timely reimbursement and appropriate utilization.

Skills

Case management

Discharge planning

Care coordination

Utilization review

InterQual criteria

Medical necessity

Physician communication

Quality improvement

Education

Registered Nurse (RN)

Tools

Electronic Health Record (EHR)

InterQual criteria

Job description

Requisition Number:

R-23466

Facility:

LOC0001 - 55 Fogg Road55 Fogg Road

Weymouth, MA 02190

Department Name:

SSH Care Progression

Status:

Full time

Budgeted Hours:

40

Shift:

Day (United States of America)

Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Case Manager is on-site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.

Compensation Pay Range: $117,707.20 - $170,768.00

1. The RN Case Manager is responsible for reviewing the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
   • Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
   • Identifies cases daily that fail to meet criteria and refers these cases to appropriate manager or physician advisor for secondary review.
   • Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity
   • Contacts the attending physician to notify him/her of decision to issue notice of non-coverage. Explains UR process and insurance coverage requirements. Obtains physician written concurrence when necessary; e.g., Medicare patients.
   • Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission. Issues the termination letter for the Medicare patient
   • Reinstates insurance coverage when patient condition becomes acute and meets criteria again. Issues reinstatement letter.
   • Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payor/insurance guidelines.
   • Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
   • Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/guidelines.
2. Plays an essential role in assisting physicians, nursing and staff with accurate determination of a patient's observation status. The RN Case Manager is an important resource in preventing delayed discharges of observation patients.
   • Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
   • Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient. Refers the questionable status to internal physician advisor or EHR according to the Departmental Process.
   • Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the level of care, utilizing InterQual for Observation.
   • Works with physicians, nursing and staff, patients and families to arrange prompt and safe discharge
   • RN Case Manager must take telephone orders from physicians changing patient status from observation to inpatient admission. This should be done when monitoring observation status. A call or page should be made to physician if the RN Case Manager believes that this should be an inpatient admission and not wait until the 24 hours are ending before conversion. RN Case Manager must actively monitor patients on observation status and seek to clarify their status as close to the 24-hour benchmark as possible. The RN Case manager must send a concern in a timely fashion to facilitate the patient being put into the correct patient status and to provide timely notification.
3. Participates in case finding and pre-admission evaluation screening to assure reimbursement.
   • Identifies potential transition planning