Case Manager

Case Manager (260514-50014646) Purpose of Position: The Case Manager is responsible for the timely facilitation and coordination of patient care for a specific patient population. The role involves working effectively with the interdisciplinary team to plan and implement individualized care programs that promote high-quality, efficient, and cost-effective care. The Case Manager assesses patient needs using established standards, Care Maps, and approved clinical guidelines, and through ongoing communication with third-party representatives facilitates care that meets patient needs and optimizes reimbursement. Responsibilities Screen new admissions daily for discharge planning needs, prioritizing visits based on screening criteria, and verifying accuracy of demographics and payer information. See patients with identified follow-up needs within one business day, completing initial assessments in InterQual and reassessing every three days as needed. Review appropriateness of patient admission and level of care needs (Inpatient and Observation) using InterQual Criteria and follow policy if level of care is not met. Initiate HINN notices and letters of reinstatement, coordinate patient appeal rights under the Discharge Appeals program. Identify patients and families with high-risk complex psychosocial, financial, and legal needs and refer them to appropriate resources. Perform utilization review on assigned unit and respond to third-party payer requests for concurrent clinical information to support ongoing services. Work closely with attending physicians and the interdisciplinary team to ensure care and discharge plans align with patient needs and covered services. Participate in unit daily rounds and care conferences across the continuum. Advocate for patients by communicating with families, payers, and the healthcare team about insurance coverage and care requirements. Coordinate thorough referral information for safe transfer to other facilities or agencies, completing required paperwork. Apply approved standards of care, Care Maps, and clinical pathways in evaluating and monitoring patient progress. Evaluate length of stay for appropriateness per InterQual criteria and make referrals to Physician Advisor when criteria are not met. Identify days at risk for denial and initiate strategies to facilitate timely discharge. Assist medical coders in obtaining diagnostic and procedural information for appropriate reimbursement. Maintain departmental policies, quality assurance, safety, environmental, and infection control standards. Stay current with regulatory and payer requirements and core clinical competency. Participate in education programs, in-services, and meetings as required. Demonstrate flexibility, cooperation, and teamwork, performing other duties as assigned. Qualifications Read, write, and communicate in English. Current registration as a Registered Nurse in Massachusetts. Bachelor of Science Degree in Nursing (preferred for external applicants). Certificate in Case Management, CPUM, or specialty (preferred). Minimum 3 years acute-care experience within the past 5 years, with broad clinical experience in a hospital setting or case management. Recent experience (within 4 years) in discharge planning and utilization review. Working knowledge of InterQual or an equivalent system. Strong interpersonal and negotiation skills, with a positive, professional demeanor. Excellent organization and time-management skills. Ability to work independently and manage a fast-paced, multiple-project environment. Proficient computer skills and ability to integrate software systems into practice. Schedule Details 40 Hours Per Week, 8:00 a-4:30 p, Every Other Weekend & Holiday (Primary Focus: Utilization Review) Organization Cape Cod Hospital Primary Location Massachusetts - Hyannis Department CCH-Care Management Compensation Annual/Hourly: Hourly – $42.04 – $89.99 per hour. #J-18808-Ljbffr Cape Cod Healthcare Inc