Job Description Summary
Hiring Event! We are hiring caring Case Managers across the health system! Please come meet our hiring managers and recruiters on Wednesday, October 2nd from 1-6pm at 549 Columbian Street in Weymouth. On the spot interviews, light refreshments, and all of the information you need to see why South Shore Health is the place for you!
Pay rate range based on experience: $53.00/hr -- $67.22/hr
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. The Case Manager looks for opportunities to reduce costs while assuring the highest quality of care is maintained. Responsibilities include applying review criteria to determine medical necessity for admission and continued stay, providing clinically-based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality healthcare. The Case Manager works collaboratively with interdisciplinary staff internal and external to the organization and 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 is required to work a weekend rotation and also an occasional holiday.
Job Responsibilities
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.
1. Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission, and continued stays.
2. Identifies cases daily that fail to meet criteria and refers these cases to the appropriate manager or physician advisor for secondary review.
3. 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.
4. Contacts the attending physician to notify him/her of the decision to issue notice of non-coverage and explains UR process and insurance coverage requirements.
5. Reinstates insurance coverage when patient condition becomes acute and meets criteria again, issuing a reinstatement letter.
6. Provides clinical data/information to contracted third-party payers while the patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
2. Plays an essential role in assisting physicians, nursing, and staff with accurate determination of a patient’s observation status.
1. Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
2. Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of the patient.
3. Participates in case finding and pre-admission evaluation screening to assure reimbursement.
1. Identifies potential transition planning problems in a timely manner to set up services required.
2. Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals.
4. The RN Case Manager is responsible for assessing patient acute level of care needs and works to implement and coordinate interventions aimed at facilitating a safe and timely discharge plan.
1. Executes and implements a safe and effective discharge plan based on the case management assessment.
2. Proactively uncovers barriers to early/timely discharge and overcomes them.
5. Interacts, communicates, and intervenes with the multi-disciplinary healthcare team in a purposeful, goal-directed fashion.
1. Establishes a means of communicating and collaborating with physicians and other team members.
2. Explores strategies to reduce length of stay and resource consumption.
Job Requirements
Minimum Education: Registered Nurse, Bachelor's 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.
Required Additional Knowledge and Abilities: Demonstrated skills in negotiation, communication, conflict resolution, interdisciplinary collaboration, and critical thinking. Knowledge of healthcare financing, community resources, and patient care processes is essential.
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