RN Case Manager

2 weeks ago

Weymouth, Massachusetts, United States South Shore Health Full time
Job Title: RN Case Manager

Join South Shore Health as a RN Case Manager and play a vital role in ensuring the highest quality of care for our patients. As a key member of our care team, you will be responsible for coordinating, negotiating, and managing the care of complex patients to achieve quality and cost-efficient patient outcomes.

Key Responsibilities:
  • Review medical records to ensure appropriate utilization and delivery of care
  • Determine medical necessity for observation, admission, and continued stays using Interqual Criteria and payor-specific criteria
  • Identify cases that fail to meet criteria and refer them to appropriate managers or physicians for secondary review
  • Communicate with attending physicians to clarify clinical documentation and obtain necessary information
  • Notify patients and/or next of kin of insurance coverage termination and issue termination letters as needed
  • Reinstate insurance coverage when patient condition becomes acute and meets criteria again
  • Continuously review patients using criteria and determine need for continued hospitalization based on third-party payer guidelines
  • Provide clinical data and information to contracted third-party payers to ensure continued reimbursement
  • Facilitate and coordinate patient care rounds and team meetings
  • Implement interventions to achieve patient goals and coordinate necessary resources
  • Proactively identify and address barriers to early and timely discharge
Requirements:
  • Registered Nurse (RN) with a Bachelor's degree preferred
  • 3-5 years of acute care hospital experience preferred, with Critical Care or Emergency Department experience highly desirable
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification within two years of hire
  • Excellent verbal and written communication skills, with ability to adapt to changing priorities and regulations
What We Offer:
  • A dynamic and supportive work environment
  • Opportunities for professional growth and development
  • A competitive salary and benefits package
  • A chance to make a meaningful difference in the lives of our patients and their families

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