Case Manager
Company: UMass Memorial Health Care
Location: leominster
Posted on: May 3, 2021
Job Description:
Title: Case Manager (RN)
Department: Discharge Planning
Requisition #: 212883
Hours: Per Diem
Shift: Day shift as needed and as available, and including
occasional weekend and holiday shifts to meet the needs of the
department.
Union: Non-Union
Posting Date: 3/4/2021
Status: Exempt/Salaried
Location: HealthAlliance, Leominster Campus
- Inpatient Hospital Case Management Experience required.
- Inpatient Utilization Review Experience required.
- Emergency Department Case Management Experience preferred.
- Certification in Case Management or pursuit of certification in
the next 3
years is preferred.
GENERAL SUMMARY:
The Case Manager provides clinically-based case management (CM)
to support the delivery of effective and efficient patient care.
Has the overall accountability for the utilization management, care
coordination and discharge planning for the patients within the
assigned caseload. Collaborates with other members of the health
care team to identify appropriate utilization of resources and to
ensure maximum reimbursement. Utilizes criteria to confirm medical
necessity for admission and continued stay. With the patient,
family and health care team, creates a discharge plan appropriate
to the patients needs and resources.
PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:
Job duties specific to this position:
- Introduces self to the patient/family, explains CM, and
provides patient with contact information.
- Completes an initial screen of all patients within 24 hours of
admission utilizing specific criteria to identify needs related to
utilization management.
- Evaluates patients for appropriateness of admission type and
setting, utilizing a combination of clinical information, screening
criteria and third party information.
- Appropriately uses Interqual criteria for leveling of
care.
- Ensures appropriate level of care documentation by the
physician.
- Conducts concurrent admission and continued stay reviews based
on appropriate utilization criteria, established standards,
procedures and policies.
- Documents authorization numbers, days approved data, and denial
data as outlined in the departmental policy and procedures
- Assess the needs for a Medicare IM, delivers admission notice
if not already done so by admitting.
- On a daily basis, identifies cases that fail to meet criteria
and promptly reviews the case with the patients physician to
resolve the issue.
- Elevates complex cases to the Director of CM and/or the PA
advisor appropriately
- Collaborates with the third party payers to anticipate denial
of payment and proactively addresses issues contributing to a
potential denial.
- Proactively follows and intervenes on open cases to include
concurrent appeals of denials.
- Retrospectively addresses denials by reviewing the patient
record and case management worksheets. Writes the letter of appeal
for pertinent denials.
- Contacts the attending physician to notify him/her of all
decisions to issue a notice of non-coverage for all payers.
- Informs the patient and/or next of kin when third party
benefits must be terminated. Issues the termination letter
following established hospital policy.
- Identifies trends related to reimbursement and communicates to
the Director.
- Educates staff and physicians about managed care principles,
observation status, discharge planning, reimbursement rules and
range of patient care setting beyond observation, intensive care
and acute hospitals.
- Collaborates with members of the multidisciplinary team to
facilitate the case management and care coordination processes for
the assigned caseload.
- Facilitate care coordination rounds.
- Participate in complex care/extended stay rounds with the PA
advisor.
- Refers appropriate cases to social work (SW) based on
established referral criteria and professional judgment.
- Consults with medical staff as needed to facilitate accurate
documentation and to assure an appropriate timely discharge.
- Monitors patient progress and plan of care with the aid of
internal and external utilization guidelines.
- Makes every attempt to prevent readmissions.
- Facilitates a patient-specific, safe discharge plan to the
appropriate setting.
- Assesses the patient/family for care needs during
hospitalization to establish an effective discharge plan in
collaboration with the patient and the multidisciplinary team.
- Identifies potential barriers to discharge or transfer and
communicates them to the care team to spearhead resolution of the
issues where possible.
- Delivers second IM notice to Medicare recipients if
appropriate, facilitating appeal if needed.
- Reports issues and system barriers to efficient and effective
discharge planning to the Director.
- Communicates with or makes referral to the patients Outpatient
CM.
- Make follow up phone calls to the patients regarding the
understanding of and compliance with the discharge plan.
- Contributes in a positive manner to the development of the CM
department.
- Communicates information in a clear and timely manner.
- Although the CM assignments are unit based, each case manager
is expected to cross cover other areas as needed and
requested.
- Documents in the patient record according to department
policies and procedures.
- Seeks and provides peer consultation about cases that are
presenting problems and/or experiencing significant deviation from
the plan of care.
- Participates in quality improvement and evaluation processes
related to the CM practice.
- Participates in the development of procedures, roles, systems
and structures related to the CM practice.
- Interacts with patients, families, colleagues and external
contacts with respect, sensitivity and attentiveness to promote
teamwork and cooperation.
- Adheres to CM department specific and organizational policies
and standards such as as TJC, Dept of Health, etc.
- Participates in activities of professional associations as
appropriate.
- Participates and assists in departmental studies and projects
as assigned.
- CMs are on site and available seven days a week as well as
holidays. Therefore, CMs are required to work weekend end rotations
and holidays are scheduled.
Job duties for all positions:
- Takes responsibility for ensuring that all work outcomes
satisfy the HealthAlliance-Clinton Hospital Three Pillars: Finance,
Quality, and Service Excellence.
- The individual must support the mission, vision, and goals of
the Hospital and serve as a role model for the CARES - It Happens
Here customer service initiative.
- Demonstrates excellent attendance and actively participates in
a variety of meetings and training sessions as required.
- Demonstrates a friendly, responsive, service-minded attitude to
all internal and external customers.
- Communicates ideas effectively. Shares information and keeps
others properly informed. Gives, and is open to useful
feedback.
- Adheres to the Hospital Code of Conduct and Behavior Standards
and dress code.
- Complies with established environment of care/safety policies
and procedures and all health and safety requirements.
- Maintains, and fosters, an organized, clean, safe work
environment.
- Actively contributes to the development and application of
process improvements.
- Maintains a collaborative, team relationship with peers and
colleagues in order to effectively contribute to the groups
achievement of goals and to help foster a positive work
environment.
- Demonstrates respect for the diversity of patient and employee
populations. Supports and encourages diverse points of view, work
and lifestyles.
- Practices cost containment and fiscal responsibility through
the efficient use of supplies, equipment, time, etc.
- Performs a variety of related duties as assigned.
JOB REQUIREMENTS
JOB KNOWLEDGE AND SKILLS:
- Ability to establish priorities, meet deadlines and maintain
productivity standards in the management of the work
assignment.
- Ability to form positive, collaborative relationships with
hospital staff, patients, families and post acute providers.
- Ability to problem solve in a proactive, creative manner, using
sound judgment based on factual information and clinical
knowledge.
- Ability to effectively negotiate with internal and external
providers of patient care services.
- Ability to assess data reflective of the patients status and
interpret the appropriate information needed to identify each
patients requirements relative to his/her age-specific needs and to
provide the care they need.
- Ability to develop leadership skills and to serve as a role
model for clinical staff.
- Ability to work rotating weekends and holidays.
- Strong computer skills including the ability to rapidly learn
and use new applications.
- Ability to work independently.
- Ability to read, write and speak clearly in English.
EDUCATION:
Requisite education for RN is required. BSN degree preferred or
actively working towards BSN. Min. ADN with significant experience
required.
EXPERIENCE:
- Minimum of 5 years of broad clinical experience, predominately
in medical/surgical nursing. CM, discharge planning and utilization
review experience preferred.
An equivalent combination of education and experience which
provides proficiency in the areas of responsibility listed above
may be substituted for the above education and experience
requirements.
LICENSES, CERTIFICATIONS, ETC. :
- Registered Nurse, licensed in Massachusetts.
- Certification in Case Management preferred.
Keywords: UMass Memorial Health Care, Leominster , Case Manager, Other , leominster, Massachusetts
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