Under the general supervision of the Director of Care Management, the RN Case Manager provides clinically-based case management to support the delivery of effective and efficient patient care consistent with the Centers for Medicaid and Medicare Conditions of Participation. The RN Case Manager will collaborate with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilize criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, create a post-acute care plan appropriate to the patient's needs and resources and facilitate this transition in concert with that patient's inpatient and post-acute care teams.
Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria (i.e.- Interqual) to identify needs related to utilization management and post-acute care planning. Based on input and direction from the multi-disciplinary team, facilitate safe and appropriate post-acute care services integrating patient and family preferences. Conduct accurate concurrent reviews using InterQual criteria; initiate payer contact, and communicate clinical review data to relevant parties. Perform a comprehensive review of the medical record to ensure documentation of appropriate level of care status. Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Refers appropriate cases to social work team members based on established referral criteria. On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient's physician to resolve the issue. Refers unresolved cases to the Director of Care Management and the Associate Medical Director of Utilization Management in a timely manner. Identifies high-risk patients to promote coordination of services and to prevent avoidable readmissions and/or Emergency Department visits. Educates staff and physicians about CMS requirements and the Conditions of Participation (CoP). Captures and trends practice, systems, operations, and patient/family issues that result in potentially avoidable days. Performs other duties as assigned.
Education: Graduate of an accredited school of nursing Bachelor of Science in Nursing is required.
Licensure and Certifications: Current Massachusetts RN license. Certification in Case Management preferred. Current American Heart Association Basic Life Support (BLS) Certification
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