Case Manager

Case Manager

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Clinical Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient's plan of care as directed. Provides professional nursing care to patients. Requires a nursing license. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects/processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

This position is responsible and accountable for the management of care for an assigned patient population by unit, across the continuum of care. The Case Manager works to achieve daily clinical, quality and cost outcomes by providing well-coordinated experiences for patients/families through the synchronization of care activities of multiple disciplines and negotiating with third party payors. This is accomplished by negotiating, procuring and coordinating services and resources needed by patient/family; ensuring and facilitating the achievement of quality and clinical customer service; cost and clinical outcomes; intervening at key points for individual patients; addressing and resolving patterns or issues that have a negative quality-cost impact; and creating opportunities and systems to enhance outcomes.

Minimum Qualifications:

• Associate’s Degree in Nursing.
• Basic Life Support (BLS) Certification.
• Registered Nurse (RN) License.
• Three (3) years of Case Management experience.
• Certifications (i.e. ACLS, PALS) relevant to the department and type of care being provided may be required.

Preferred Qualifications:

• Bachelor’s Degree in Nursing.

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

• Completes assessments on all new admissions to determine the need for all appropriate Case Management services.
• Conducts daily multidisciplinary rounds on assigned units, reviews patient’s plan of care and coordinates including: Assessment of patient/family needs; Completion and report of diagnostic tools in a timely manner; Completion of treatment appropriate for the acute episode of illness; Modification of plan to meet continuing care needs of the patient; and Monitors ongoing process of gathering adequate information from all relevant sources to insure operation of plan.
• Discusses estimated length of stay, treatment and discharge plan with the attending physician and healthcare team by establishing strong, collaborative relationships with physicians and team members and discusses the appropriateness of resource utilization, consults and treatment plan.
• Ensures that the interdisciplinary care plan and discharge plan are consistent with the patient’s clinical course, covered services and continuing care needs.
• Identifies patients and families with complex psychosocial, financial and legal discharge planning needs and refers them to social work.
• Incorporates knowledge of clinical expertise, quality initiatives, insurance and finance into decision-making and problem solving of individual patient cases and across case type during care management activities.
• Fosters and maintains a positive working relationship with referral agencies and liaisons to enhance patient flow.
• Collects and reports on quality projects, i.e. CHF; Re-admissions within 30 days; Delay Day Variances; Risk management; and Quality improvement.
• Documents patient/family progress towards discharge and all critical events and information associated with the hospital stay in SoftMed.
• Supports the EMR and all computer programs, including SoftMed and Soarian.
• Using Interqual criteria, reviews appropriateness of admission, the need for continued stay and information needed for discharge.
• Responds to third party payor requests for concurrent clinical information in timely manner.
• Ensures that documentation in the medical record supports the admission and continued stay, in order to reduce denial rate.
• Documents care management activities in the initial assessment and as the patient progresses towards discharge and at discharge.
• Interacts with Admitting, Financial Counselors, Insurance Case Managers, Finance and Screeners as appropriate.
• Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities.
• Works with documentation specialist to have accurate length of stay information.
• Provides superior customer services to all internal and external clients, customers and patients.
• Completes roles and functions related to discharge planning/coordination including case identification, high risk screening, assessment of patient and resources, goal setting, implementing, maintaining and evaluating process. Goal is to complete within 24 hours.
• Coordinates all discharge activities and initiates all appropriate referrals to continuum of care agencies in a timely manner.
• Facilitates patient transfer from one level of care to the next.

Physical Requirements:

• Prolonged, extensive, or considerable standing and walking.
• Lifts, positions, pushes and/or transfers patients.
• Considerable reaching, stooping, bending, kneeling, crouching.
• Regularly exposed to the risk of blood borne diseases.
• Contact with patients under wide variety of circumstances.
• Subject to varying and unpredictable situations.
• Handles emergency and crisis situations.

Skills & Abilities:

• Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities
• Working knowledge of InterQual or designated screening tool.
• Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
• Incorporates the highest standard of professional, clinical, legal and ethical practice into their own daily practice (i.e. patient's rights, maintains confidentiality, role model to nursing).

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

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