RN Case Manager
2 weeks ago
The RN Case Manager (CM) facilitates a discharge plan including the coordination of post acute care/services for patients admitted to Medical, Surgical, Pediatric, or Obstetrical Services, and as needed, for hospital outpatient areas including but not limited to the Emergency Department and Henderson Surgical Center. The CM may also oversee the coordination of care for both inpatient and outpatient of those patients identified as high risk for readmission. The CM will develop and implement discharge plans for those patients identified as needing post acute discharge services or post acute follow up in collaboration with the patient/legal representative, health care team/provider, insurer, and others, including community based organizations, as needed. The CM uses a collaborative process of assessment, planning, facilitation, and advocacy.
She/he may use a high-risk screening criteria or other acceptable screening tools to determine what patients may benefit from specialized care coordination services. The CM consults and collaborates with physicians regarding medical necessity of admissions and appropriate level of care for hospitalized patients utilizing nationally accepted criteria. He/she routinely reviews patients' health records and communicates with the health care team/provider to ensure continued appropriate level of care, compliance with Federal and State regulations related to discharge planning, compliance with CMS regulations or other third party payers and appropriate utilization of hospital and medical resources.
The CM completes timely and accurate insurance reviews as requested by third party payers. The CM will serve as a resource for physicians, hospital staff, and patients and their families in providing information about insurance coverage, limitations of coverage related to discharge planning, community resources, community referrals and post acute care options. He/she participates in quality and risk management case finding activities.
The role requires the ability to offer creative, problem solving solutions using sound and prudent clinical judgment and within the scope of licensure and according to case management standards of practice. The CM seeks out educational and self-development opportunities related to care coordination, transitions of care, healthcare reimbursement, and other pertinent areas.
Education/Licensures/Certifications
* Graduate of an accredited school of nursing. BSN preferred
* Current licensure as a Registered Nurse in the Commonwealth of Massachusetts, with minimum of three years' clinical experience
* Evidence of continued education and professional development. CCM or ACMA certification preferred
Experience
* Prior experience in the following areas:
o general acute care hospital experience
o healthcare reimbursement including utilization review
o quality improvement
o enhanced models of health care delivery
* Previous acute care hospital care coordination/discharge planning required
* Knowledge of the special needs and behaviors of infant, child, adolescent, adult, older adult patients preferred
Skills and Abilities
* Requires the ability to work independently and establish an effective relationship with physicians, office staff, and health care providers in physician's offices, community based organizations, hospitals, and other health care facilities
* Requires autonomy in decision making using sound judgment based upon factual information, clinical experience, and nursing process
* Requires ability to seek out and identify resources to problem solve issues
* Ability to work within a multidisciplinary environment
* Requires ability to be cross trained for coverage of other RN CM assignments
* Requires flexibility to cover assigned shift hours as determined by departmental need
* Basic computer skills including knowledge of Microsoft products and efficient data entry ability
* Effective written and verbal communication skills
* Excellent organizational skills
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