RN Case Manager: Discharge Planning & Utilization

Vertek Solutions, Inc.; Massachusetts; On-site; USD 85,000 - 105,000; Full time

Job summary

Vertek Solutions, Inc. is seeking a Registered Nurse licensed in Massachusetts with strong discharge planning and utilization review experience.

The role focuses on screening admissions, prioritizing visits, and coordinating care with InterQual criteria to ensure appropriate level of care and timely patient advocacy. Responsibilities include daily screening, documentation accuracy, and collaboration with physicians and the care team to support efficient discharge planning and payer

Qualifications

• RN license in Massachusetts
• 3 years acute care experience within past 5 years with broad clinical experience in a hospital setting or case management
• Working knowledge of InterQual®, or equivalent system
• Recent knowledge/experience within past 4 years in Discharge Planning and Utilization review - Dyad

Responsibilities

• Screen new admissions daily for discharge planning needs.
• Establish priority of visits based on screening criteria.
• Verify accuracy of demographics and payer information and notify admissions of corrections.
• Patients with identified needs for follow-up seen within one business day; Initial Assessment completed in InterQual®.
• Reassessments every 3 days as needed for changes in medical status or caregiver.
• Review appropriateness of admission and level of care needs using InterQual® criteria; follow policy if not met.
• Initiates timely HINN notices and reinstatement letters.
• Coordinate patient appeal rights under Discharge Appeals program.
• Identify high-risk psychosocial/financial/legal needs and refer to resources.
• Responsible for utilization review on assigned unit.
• Facilitate third-party payer requests for concurrent clinical information; respond by day end.
• Work closely with attending physician and interdisciplinary team.
• Ensure care plans and discharge plans align with patient needs and services.
• Participate in unit rounds; advocate for patients with families, payers and healthcare team.
• Act as patient advocate regarding adverse determinations and insurance-related issues.

Skills

RN License MA

Acute care experience

Tools

InterQual®

Job description

Vertek Solutions, Inc. is seeking a Registered Nurse licensed in Massachusetts with strong discharge planning and utilization review experience.

The role focuses on screening admissions, prioritizing visits, and coordinating care with InterQual criteria to ensure appropriate level of care and timely patient advocacy. Responsibilities include daily screening, documentation accuracy, and collaboration with physicians and the care team to support efficient discharge planning and payer