Case Manager
Case Manager
Posted on :
11-04-2025
Employer Active
1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
11-04-2025
Job Description
Job Summary:
Responsible for the planning development and organization of the operations of the Case Management Department and the Swing Bed Program. Assumes accountability for managing and coordinating continuum of care activities for acute and swing bed patients. Assures optimization of utilization resources service delivery achievement of clinical quality financial and patient satisfaction goals. The scope of this role includes supporting thirdparty payor contracting minimizing clinical denials and facilitating reimbursement of services. Responsibilities also include compliance with external review agencies requirements and external auditing practices. Is accountable for the development of the performance improvement program in relationship to Case Management.
Participates in developing the annual departmental budget; identifies and monitors operational costs to maximize utilization of material and human resources.
Develops departmental and professional goals to support the organizations mission vision and strategic direction.
Principal Duties and Responsibilities
Utilization Management
- Admission chart review within 24 hours of admission. Covers ED SDS and Direct Admissions and Swing Beds to NCH.
- Performs admission and concurrent utilization review to identify medical necessity correct patient status level of care and appropriateness of setting.
- Applies utilization review criteria (InterQual) to identify patients who do not meet acute stay criteria. Seeks further information from the attending physician.
- Demonstrates knowledge of local state federal guidelines and Joint Commission regulations.
- Demonstrates skills and knowledge necessary to perform clinical review on adult geriatric and neonatal patients.
- Provides necessary clinical information to insurance companies as requested to secure admission and continued stay authorization.
- Presents Letters of NonCoverage to patients and/or families when inpatient admission does n Collaboratively responsible for ensuring that there is a multidisciplinary plan of care to meet identified patient outcomes.
- Identifies system issues that serve as barriers to care. Participates in development and implementation of strategies to remove barriers and promote resolution through coordination of a problem solving process.
- Establishes an environment of cooperation and communicates between medical staff hospital staff internal and external case managers third party payers primary care givers and care coordinators for medical necessity and appropriateness.
- Tracks all avoidable days for trending and root cause analysis.
- Works with appropriate staff to develop processes to prevent denials and improve reimbursement.
- Pursues within twentyfour hours any nonreply by physician to reviewers request for documentation.
- Offers educational information to physicians and clinical staff as necessary.
- Collaborates with the Physician Advisor to resolve ongoing length of stay/denial issues.
- Monitors CMS state and thirdparty changes and leads organizational efforts related to regulatory and payor requirements.
- Supports corporate compliance initiatives to meet existing and new requirements.
- Acts as an organizational liaison with external agencies related to third party payments including the Quality Improvement Organization for CMS.
Denial and Appeals Management
- Coordinates clinical appeals.
- Demonstrates skills and knowledge necessary to write a clinical appeal for adult and pediatricpopulations.
- Reviews all clinical denials received by the payors and or Recovery Audit Contractor for appeal.
- Reviews and obtains medical records as appropriate in order to respond to all written faxed and emailed denial letters timely.
- ot meet criteria and/or if acute continued stay is no longer necessary.
- Prepares all levels of appeals utilizing relevant clinical information within the allotted timeframe per Managed Care Organization contract and Recovery Audit Contractor timelines.
- If first level of appeal decision is upheld then pursues 2nd and 3rd level appeal as appropriate.
- Followsup with managed care companies to ensure timeframe for appeal response is timely. Sends letter to insurer as needed.Coordinates auditing activity from external payors
- Knowledgeable of NCH managed care contracts in relation to appeal levels and time frames.
- Assists in maintaining data base to ensure that deadlines for response are not missed and pertinent appeal information is documented.
- Upon receipt of notification of payment on an account or no appeal recommended on an account these accounts are closed within CPSI.
- Supports the Finance Department in account resolution and the appeal process for such.
- Prepares reports as requested by the CFO/CNO for various utilization/ finance meetings.
- Represents Case Management as requested by the CFO/CNO on various committees.Discharge Planning
- Assesses the physical functional social psychological environmental and financial needs of patients; identifying a costeffective comprehensive plan to meet the families service needs and implement the plan within 24 hours of admission and/or next business day.
- Assess the patients formal and informal support systems.
- Provide patient with choice and have appropriate forms filled out.
- Provides referrals to appropriate community resources; facilitating access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and coordinate services to avoid duplication.
- Monitor the patients progress toward goal achievement and periodically reassess changes in health status. Consults with primary physician or designee and other members of the care delivery team as needed.
- Act as a patient advocate; identify and develop new community resources in collaboration with the social work department and assist with problem solving.
- Conducts patient education; collaborates with patient to establish realistic goals and activities to enhance patient selfmanagement and participation.
- Conducts multidisciplinary patient rounds on assigned unit(s).
- Actively participates in multidisciplinary case conferences and/ or family conferences.
- Collaborates with the interdisciplinary team in the case management of high risk patients who are clinically complex and/or require long term care or postacute care services.
- Facilitates continuity of care for patients with chronic disease throughout the system through utilization of appropriate organizational resources while demonstrating genuine caring.
- Provides patient and/or family with the Important Message from Medicare if needed.
- Accurately document discharge assessment in the medical record
- Maintain patient confidentiality
- Develop and maintain positive relationships with internal and external customers.
Essential Knowledge Skills and Abilities Required for the Position
- Registered nurse with Bachelors in Nursing.
- Minimum of three to five years recent acute clinical practice; Case Management experience preferred.
- Certification in Case Management preferred and/or ability to obtain within one year of employment.
- Professional RN licensure in the State of Massachusetts in good standing
- Knowledge of hospital computer systems; proficiency in using these systems.
- Knowledge of nursing principals practices and processes.
- Knowledge of case and disease management principals practices and processes.
- Knowledge of regulatory agency standards for utilization review and performance improvement
- Knowledge of hospital requirements under Medicare Medicaid and third party payers
- Knowledge of Nantucket performance improvement utilization discharge and risk management plans.
- Knowledge of pharmacological agents potential side effects and monitoring requirements.
- Knowledge of utilization review criteria such as InterQual.
- Ability to critique medical records using established criteria to determine discharge needs.
- Ability to maintain optimal level of self education relevant to the clinical areas worked.
- Ability to act independently within established procedures policies and guidelines.
- Ability to communicate utilization management restrictions to schedule specific tests in a timely manner with ancillary services.
- Ability to assign appropriate patient status and length of stay.
- Skilled in oral and written communications.
- Skilled in analytical problemsolving.
- Ability to exercise tact judgment and diplomacy.
- Ability to multitask and critically think.
- Ability to relate to people in a manner to gain confidence and establish support.
- Ability to walk to and from patient care areas.
- Ability to stand for extended periods of time.
- Ability to lift and carry up to twenty 20 pounds including but not limited to computer and medical records.
- Frequent finger dexterity near vision and repetitive motion as required for daily computer use.
Required Experience:
Manager
Employment Type
Full-Time
Key Skills
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