RN- Inpatient Case Manager
Company: Cambridge Health Alliance
Posted on: July 16, 2021
Under the general supervision of the Director of Care
Management, the RN Case Manager provides clinically-based case
management to support the delivery of effective and efficient
patient care consistent with the Centers for Medicaid and Medicare
Conditions of Participation. The RN Case Manager will collaborate
with other members of the health care team to identify appropriate
utilization of resources and to ensure reimbursement. Utilize
criteria to confirm medical necessity for admission and continued
stay. With the patient, family and health care team, create a
post-acute care plan appropriate to the patient's needs and
resources and facilitate this transition in concert with that
patient's inpatient and post-acute care teams.
Completes an initial screen of all patients within 24 hours of
admission utilizing specific criteria (i.e.- Interqual) to identify
needs related to utilization management and post-acute care
planning. Based on input and direction from the multi-disciplinary
team, facilitate safe and appropriate post-acute care services
integrating patient and family preferences. Conduct accurate
concurrent reviews using InterQual criteria; initiate payer
contact, and communicate clinical review data to relevant parties.
Perform a comprehensive review of the medical record to ensure
documentation of appropriate level of care status. Collaborates
with the third party payers to anticipate denial of payment and
proactively addresses issues contributing to a potential denial.
Refers appropriate cases to social work team members based on
established referral criteria. On a daily basis, identifies cases
that fail to meet criteria and promptly reviews the case with the
patient's physician to resolve the issue. Refers unresolved cases
to the Director of Care Management and the Associate Medical
Director of Utilization Management in a timely manner. Identifies
high-risk patients to promote coordination of services and to
prevent avoidable readmissions and/or Emergency Department visits.
Educates staff and physicians about CMS requirements and the
Conditions of Participation (CoP). Captures and trends practice,
systems, operations, and patient/family issues that result in
potentially avoidable days. Performs other duties as assigned.
Education: Graduate of an accredited school of nursing Bachelor
of Science in Nursing is required.
Licensure and Certifications: Current Massachusetts RN license.
Certification in Case Management preferred. Current American Heart
Association Basic Life Support (BLS) Certification
Experience: Hospital Care Management Experience strongly
preferred. 3-5 years of medical/surgical RN experience OR 3-5 years
of other RN Case Management experience is required.
Keywords: Cambridge Health Alliance, Cambridge , RN- Inpatient Case Manager, Other , Cambridge, Massachusetts
Didn't find what you're looking for? Search again!