Case Manager

If you are an existing employee of South Shore Health then please apply through the internal career site. Requisition Number: R-22541 Facility: LOC0001 - 55 Fogg Road, Weymouth, MA 02190 Department Name: SSH Care Progression Status: Full time Budgeted Hours: 40 Shift: Day (United States of America) Compensation Pay Range: $117,707.20 - $170,768.00 1. Review Medical Records and Determine Utilization 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 the necessary clinical documentation required to help support medical necessity. Contacts the attending physician to notify them 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 the patient’s condition becomes acute and meets criteria again. Issues the 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 the patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request. 2. Observation Status Determination and Discharge Prevention 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. Case Finding and Pre‑Admission Evaluation Screening 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; e.g., SNF/VNA/Home Pharmacy. Identifies need for new resources if gaps exist in service continuum, and initiates creative care delivery options. 4. Assess Acute Level of Care and Discharge Planning With the Case Manager, work to identify, and prioritize workflow through identification of patient‑specific, department needs and/or unit‑based needs. 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. Implements interventions that lead to patient accomplishing goals established in Plan. Coordinates the necessary resources to accomplish goals developed in Plan. Proactively affects system to facilitate efficient flow of care, anticipates discharge process. Gathers information from multidisciplinary team and monitors appropriate discharge plan. 5. Ongoing Patient Care Coordination Uses and updates the interdisciplinary patient White Board for communication enhancement; including RN Case Manager name, time/date/plan for discharge. Issues the Medicare Important Message (IM). Uses the Medical Necessity form for post‑discharge transportation. Uses technical tools, i.e., eDischarge, EHR, Interqual, MCCM. Identifies and/or facilitates establishment of a patient’s Health Care Proxy. Identifies patient Care Plan Partner. Fosters patient and family awareness of Patient Portal. 6. Follow‑Up Care and Referral Management Ensure that, at minimum, three referrals are processed for continuum of care providers. Document choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record. Expedite and process referrals, in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary. Document response by providers. Deliver the Medicare Important Message (IM) per department protocol. Have patient, family/healthcare Proxy sign discharge plan. 7. Multidisciplinary Team Interaction and Resource Utilization Establishes a means of communicating and collaborating with physicians, other team members, the patient’s 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 pro‑active 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 comments on the patient’s clinical state. Coordinates and participates in daily multidisciplinary patient care rounds. Uses the SBAR method to communicate with MD and peers. Acts as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning for the more clinically complex or long length of stay patient. 8. Communication with Referral Sources Establishes and maintains effective communication with all referral sources, insurers, vendors and patient supplier systems. 9. Professional Commitment Maintains consistently a professional commitment to institutions and department’s goals and objectives. Demonstrates flexibility to the department’s needs in relation to floor and work schedule, and any other internal and external demands on the department. Continually shows commitment to the Department by extending self when need arises. 10. Updated Knowledge Base Maintains a working knowledge of the requirements of the payers most frequently seen with the patient population. Maintains a working knowledge of the resources available in the community for patients/families. Maintains current nursing licensure CEU credits, case management certification CEUs. Maintains Interqual certification. 11. Department Operational Excellence Manages all activities so that quality services are provided in an efficient and effective manner. Services provided meet all applicable regulatory requirements. Participates in departmental and organizational Quality Improvement initiatives involving the Lean principles and TIM WOODS. Maintains departmental productivity measurements. Has an awareness of departmental productivity measurements including LOS and utilization. Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements. 12. Goal Achievement Attains all agreed to goals and objectives within specified time frames, as part of the organization’s overall mission. 13. Technology Embrace eDischarge, EHR, Interqual, MCCM, Epic, Workday. JOB 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. Required Additional Knowledge, and Abilities: Demonstrated skills in negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, 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. Knowledge of post‑acute care community resources. Experience with Managed Care preferred. Excellent verbal and written communication skills required. Demonstrates flexibility via an ability to adapt to changing priorities and regulations. Shift Schedule: Mon‑Fri 5‑8’s or 4‑10’s. Alternating weekends and holidays. Accredited Case Manager (ACM) – National Board for Case Management (NBCM) – National Board for Case Management (NBCM), Certified Case Manager (CCM) – Commission for Case Manager Certification (CCMC) – Commission for Case Manager Certification (CCMC), RN‑Registered Nurse – Board of Registration in Nursing (Massachusetts). #J-18808-Ljbffr