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Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. *Commits to working a minimum of 32 hours, with at least 16 hours (in 2 shifts) worked during a night and/or weekend per 4 week schedule. Also works 1 major summer or winter holiday.
Job Responsibility:
Acts as a patient advocate/Case Manager
Coordinates, negotiates, procures services and resources for, and manages the care of complex patients
Applies review criteria to determine medical necessity for admission and continued stay
Provides clinically-based case management, discharge planning and care coordination
Reviews medical record of all observation and inpatient admissions and continued stays
Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining medical necessity
Identifies cases that fail to meet criteria and refers for secondary review
Contacts attending physicians on cases lacking adequate documentation
Contacts attending physician to notify of decision to issue notice of non-coverage
Informs patient and/or next of kin when insurance coverage must be terminated
Reinstates insurance coverage when patient condition becomes acute
Provides clinical data/information to contracted third-party payers
Assists physicians, nursing and staff with accurate determination of a patient’s observation status
Identifies and reviews observation patients to determine correct patient level of care
Consults with physicians, nursing, admitting, and outside insurance case managers
Assumes role of review coordinator for observation services
Works to arrange prompt and safe discharge
Takes telephone orders from physicians changing patient status
Participates in case finding and pre-admission evaluation screening
Identifies potential transition planning problems
Works with attending physician to move patient through system
Assesses patient acute level of care needs
Implements and coordinates interventions aimed at facilitating safe and timely discharge
Executes and implements a safe and effective discharge plan
Proactively uncovers barriers to early/timely discharge
Facilitates and coordinates patient care rounds
Conducts necessary conferences and team meetings
Coordinates necessary resources to accomplish goals
Uses and Updates interdisciplinary patient White Board
Issues Medicare Important Message (IM)
Proper use of Medical Necessity form for post discharge transportation
Use of technical tools
Identifies and/or facilitates establishment of patient’s Health Care Proxy
Identifies patient Care Plan Partner
Fosters patient and family awareness of Patient Portal
Ensure patient receives information related to choice of follow-up care facilities
Ensure at minimum 3 referrals processed for continuum of care providers
Document choices provided and selections made
Expedite and process referrals
Interacts, communicates, and intervenes with multi-disciplinary healthcare team
Explores strategies to reduce length of stay and resource consumption
Communicates patients at risk of losing insurance coverage
Maintains pro-active role to ensure appropriate documentation
Reviews physician documentation
Coordinate and participate in daily multidisciplinary patient care rounds
Uses SBAR method to communicate
Acts as clinical resource
Establishes and maintains effective communication with referral sources, insurers, vendors
Maintains professional commitment to institutions and department’s goals
Maintains updated knowledge base of resources
Maintains current nursing licensure CEU credits, case management certification CEU's
Maintains Interqual Certification
Responsible for department operational excellence
Manages activities so quality services provided
Services meet all applicable regulatory requirements
Participates in departmental and organizational Quality Improvement initiatives
Maintains departmental productivity measurements
Follows department policies, procedures, and standards
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
RN - Registered Nurse license
ACM-Accredited Case Manager or CCM-Certified Case Manager within two years of hire
Demonstrated skills in: negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management and ability to multitask in high stress environment
Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis
Knowledge of utilization management as it relates to third party payers
Knowledge of post-acute care community resources
Experience with Managed Care preferred
Excellent verbal and written communication skills required
Demonstrates flexibility via an ability to adapt to changing priorities and regulations
Basic computer skills required
Varied shifts and days
Weekend and holiday commitment
ACLS (AHA) Advanced Cardiac Life Support Certification
Basic Life Support (BLS) Certification
Emergency Response Training (ERT) Certification
INSTRUCTOR- Advanced Cardiac Life Support (ACLS)
INSTRUCTOR- Basic Life Support (BLS)
Neonatal Resuscitation Program (NRP) Certification
OB- Emergency Response Training (ERT)
Pediatric Advanced Life Support (PALS) Certification
RN-Registered Nurse - Board of Registration in Nursing (Massachusetts)
Trauma Care After Resuscitation (TCAR)
Trauma Nurse Core Course (TNCC)
Nice to have:
Critical Care or Emergency Department experience highly desirable