Travel Nurse RN - Case Management
Hyannis, MA
Trusted Talent
Days

Purpose of Position

The Case Manager is responsible for the timely facilitation and coordination of patient care for a specific patient population or area of assignment. Responsibilities involve working effectively with the interdisciplinary team to plan and implement an individualized program of care that promotes high quality, efficient, and cost-effective care. The Case Manager assesses patient needs using established standards, Care Maps, and other approved clinical guidelines. Through ongoing communication and coordination with third-party representatives, the Case Manager will facilitate care that meets established patient care needs while optimizing reimbursement.

Description

• Screen new admissions daily for discharge planning needs.
• Establish priority of visits based on screening criteria.
• Verify accuracy of demographics and payer information and notify admissions of corrections.
• Patients with identified needs for follow-up are seen within one business day of identification, and the Initial Assessment is completed in InterQual.
• Reassessments are conducted every three days as needed for changes in medical status, diagnosis, or caregiver.
• Review appropriateness of patient admission and level of care needs (Inpatient and Observation) utilizing InterQual Criteria and follow policy and procedure if the level of care is not met.
• Initiate timely HINN Notices and letters of reinstatement.
• Coordinate patient appeal rights under the Discharge Appeals program.
• Identify patients and families with high-risk complex psychosocial/financial and legal needs and refer to appropriate resources.
• Responsible for utilization review on the assigned unit.
• Facilitate third-party reimbursement by responding to third-party payer requests for concurrent clinical information in support of ongoing services.
• Work closely with the attending physician/interdisciplinary team to facilitate appropriate care and services.
• Ensure that the interdisciplinary care plan and the discharge plan are consistent with the patient’s required needs and covered services.
• Participate in/facilitate unit's daily rounds.
• Advocate for patients through the development of effective partnerships with patient families, payers, and the healthcare team.
• Act as a patient advocate communicating with patients/families regarding adverse determinations and other issues related to insurance coverage and ongoing care requirements.
• Facilitate and maintain patient independence in decision-making when appropriate.
• Coordinate and communicate thorough and complete referral information to enhance a safe transfer of patients to other facilities or agencies.
• Complete all necessary paperwork based on need and regulation.
• Demonstrate knowledge of community resources and act as a resource to staff in providing safe and effective post-hospital care.
• Participate and accurately apply approved standards of care/Care Maps and clinical pathways in evaluating and monitoring the patient’s clinical course.
• Participate in the development and revision of pathways.
• Participate in care conferences on patients across the continuum.
• Evaluate the continued length of stay of patients for appropriateness per recognized InterQual criteria.
• Make appropriate referrals to the Physician Advisor if criteria are not met and resolution with the attending physician cannot be accomplished.
• Identify days at risk for denial and initiate strategies to facilitate care and accomplish discharge.
• Assist medical coders by obtaining necessary diagnostic and procedural information to assure appropriate reimbursement.
• Maintain established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and Infection Control standards.
• Maintain core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
• Participate in education programs, in-services, and meetings as required.
• Recognize and understand the responsibility of this key role and the demands it places in direct support of high-quality patient care delivery.
• Ability to work independently.
• Comply with policies regarding the dress code.
• Perform other related duties as assigned or requested. Display flexibility, cooperation, and characteristics of a team member.
• Consistently deliver service excellence to all patients, family members, visitors, volunteers, and co-workers.

Qualifications

• Minimum of three years of acute care experience within the past five years, with broad clinical experience in a hospital setting or case management.
• Working knowledge of InterQual or equivalent system.
• Recent knowledge and experience within the past four years in Discharge Planning and Utilization review.
• Ability to read, write, and communicate in English.
• Current registration as a Registered Nurse in Massachusetts.
• Bachelor of Science Degree in Nursing preferred.
• Certificate in Case Management, CPUM, or specialty preferred.
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional, and cooperative demeanor.
• Excellent organization and time management skills.
• Ability to work independently and effectively in a fast-paced environment.
• Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
• Proficient computer skills with the ability to utilize and integrate updated software systems into practice.

Must Have Skills:

• Acute Care
• InterQual