RN Case Manager per-diem

South Shore Health RN Case Manager Job Description

If you are an existing employee of South Shore Health, please apply through the internal career site.

Requisition Number: R-21995 Facility: LOC0001 - 55 Fogg Road Address: 55 Fogg Road, Weymouth, MA 02190 Department Name: SSH Care Progression Status: Part-time Budgeted Hours: 0 Shift: Day (United States of America)

Job Summary:

Under the general supervision of the Case Management Manager, acts as a patient advocate/Case Manager to SSH&EC clients. This autonomous role coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost-efficient patient outcomes.

Responsibilities:

• Review medical records of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
• Assist physicians in determining medical necessity for observation, admission, and continued stays using Interqual Criteria, physician certification, and payor-specific criteria.
• Identify cases daily that fail to meet criteria and refer them to appropriate manager or physician advisor for secondary review.
• Contact attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarify necessary clinical documentation required to support medical necessity.
• Inform patients and/or next of kin when insurance coverage must be terminated for the current admission.
• Reinstates insurance coverage when patient condition becomes acute and meets criteria again.
• Continues review of all patients using criteria and determines need for continued hospitalization based on 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.

Key Responsibilities:

• Plays an essential role in assisting physicians, nursing, and staff with accurate determination of a patients observation status.
• 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.
• 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.

Additional Responsibilities:

• Participates in case finding and pre-admission evaluation screening to assure reimbursement.
• Identifies potential transition planning problems in a timely manner to set up services required.
• Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals.
• Identifies need for new resources if gaps exist in service continuum, and initiates creative care delivery options.

Discharge Planning Responsibilities:

• Assesses patient acute level of care needs and works to implement and coordinate interventions aimed at facilitating a safe and timely discharge plan to the appropriate sub-acute settings in collaboration with the Case Manager Specialist.
• Executes and implements a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
• Makes and documents appropriate changes to discharge plan when necessary.
• Proactively uncovers barriers to early/timely discharge and overcomes them.
• Facilitates and coordinates patient care rounds.
• Conducts necessary conferences and team meetings regarding specific patient needs.

Communication and Collaboration Responsibilities:

• Establishes a means of communicating and collaborating with physicians, other team members, the patients payers, and administrators.
• Explores strategies to reduce length of stay and resource consumption within the care managed patient populations, implements them, and documents the results.
• Communicates to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits, facilitates discharge plan.
• Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
• Reviews physician documentation and follows procedures to seek clarification where indicated of that documentation relative to diagnosis and comment on the patients clinical state.

Technology and Tools:

• Embraces technological solutions to work processes and practices.
• Utilizes eDischarge, EHR, Interqual, MCCM, Epic, and Workday.

Requirements:

• Minimum Education: Registered Nurse, Bachelors prepared strongly preferred
• Minimum Work Experience: 3-5 years acute care hospital experience preferred
• Critical Care or Emergency Department experience highly desirable
• Required Licenses/Registrations: RN - Registered Nurse
• Required Certifications: ACM-Accredited Case Manager or CCM-Certified Case Manager within two years of hire
• Demonstrated skills in negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management, and ability to multitask in high-stress environment.
• Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
• Knowledge of utilization management as it relates to third-party payers.
• Experience with Managed Care preferred.
• Excellent verbal and written communication skills required.
• Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
• Basic computer skills required.

Weekend and Holiday Requirement:

• Must be available to work weekends and holidays.

License/Registration/Certification Requirements:

• ACLS (AHA) Advanced Cardiac Life Support Certification - American Heart Association (AHA) (Including courses offered through SSH)
• Basic Life Support (BLS) Certification - American Heart Association (AHA) (Including courses offered through SSH)
• Emergency Response Training (ERT) Certification - SSH Education & Training
• INSTRUCTOR- Advanced Cardiac Life Support (ACLS) - American Heart Association (AHA) (Including courses offered through SSH)
• INSTRUCTOR- Basic Life Support (BLS) - American Heart Association (AHA) (Including courses offered through SSH)
• Neonatal Resuscitation Program (NRP) Certification - American Heart Association (AHA) (Including courses offered through SSH)
• OB- Emergency Response Training (ERT) - SSH Education & Training
• Pediatric Advanced Life Support (PALS) Certification - American Heart Association (AHA) (Including courses offered through SSH)
• RN-Registered Nurse - Board of Registration in Nursing (Massachusetts)
• Trauma Care After Resuscitation (TCAR) - TCAR Education Programs
• Trauma Nurse Core Course (TNCC) - Emergency Nurses Association (ENA)