Case Manager - Quality & Case Management; 40hrs / 1st Shift
The RN Case Manager is responsible for overseeing the appropriateness of care provided to members of health plans contracted by the hospital and is accountable for appropriate financial and clinical outcomes of these patients. The RN Case Manager will be assigned to selected areas of the Hospital on a rotating basis to perform utilization reviews and other Utilization Management activities, as needed based upon department staffing and coverage. The RN Case Manager will support and coordinate the activities of the Social Workers assigned to the unit. As this is an evolving position, duties and responsibilities may vary based on specific assignments.
Scope of Authority:
- Perform InterQual reviews on assigned patients and working with insurers to provide clinical information, answer questions, obtain insurance authorization for patients.
- Supports and collaborates with Social Workers who will be responsible for the development and execution of patient discharge plans.
- Assists the Social Workers to prioritize work and/or support clinically difficult discharge plans.
- Prepare and review reports on the Department's performance including but not limited to LOS, clinical denials and appeal status, avoidable days, discharge times, proper level of documentation.
- Work with Case Management Director to develop educational needs and identify strategies to accomplish objectives of the Department.
UM Reviews and Denial Support
- Perform Interqual Admission Assessments on all new commercial admissions and forward the reviews to insurers in a timely manner. Answers questions from the insurers and provides additional clinical information requested. Reviews all Medicare admissions for appropriate two midnight documentation.
- Communicate in real time with physicians on any patients not meeting criteria and establish a course of action. Work collaboratively with the physicians to help them understand documentation or leveling issues. Provide education to physicians / hospitalists regarding Inpatient vs. Observation criteria
- Obtain insurance authorization numbers in a timely manner for patients requiring inpatient, outpatient and/or post-acute authorization prior to ordering and delivering services.
- Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
- Perform concurrent/daily InteQual reviews on assigned patients. Forward all reviews to insurers on a timely basis. Answer any questions from insurers. Perform concurrent denial management to proactively resolve issues prior to discharge.
- Upon receipt of denials from insurers, review the clinical criteria and provide the insurer with additional clinical information to reverse the denial.
- Maintain a complete clinical record and profile on a patient's clinical conditions in Allscripts. Utilize the Allscripts tool appropriately completing all fields and clinical information
- Document all interaction with insurers and members of multidisciplinary team as appropriate.
- Task and communicate all denials for appeal to the Appeal Coordinator.
- Finalize authorization for all covered days prior to case closure
- Rotate to other units of the Hospital including the ED as directed by the Case Management Director and the schedule for the Department. Rotate and cover weekends and holidays as directed by the Case Management Director.
Discharge Planning and Execution:
- Review initial Admission Assessments and proposed discharge plans developed by the Social Worker providing feedback when appropriate. Identify complicated discharges and review these with the Social Worker providing guidance as needed.
- Coordinate and monitor discharge planning activities for an assigned patient population and provide support to the Social Worker and administrative staff managing the discharge process.
- Works with the multidisciplinary team to create an individualized discharge plan for high-risk patients ensuring appropriate level of services are scheduled for the patient.
- Educate physicians/hospitalists and clinical staff on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives.
- Communicate pertinent patient information with skilled nursing facilities, Community Health Agencies, physicians and other staff to insure all post-acute clinical information is provided. Information to be provided on a timely basis to not delay discharge.
- Provide feedback and collaborate with Social Worker on priority of work and any follow-up issues.
- Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate.
- Provide patient education and family teaching on an as needed basis.
- Act as an advocate for the patient.
- Promote nursing care within legal, ethical and professional standards.
- Facilitate/coordinate multidisciplinary care patient care rounds on medical/surgical units, as needed.
- Attend Utilization Management meetings as appropriate
- Maintain daily tracking tools to assist the Department to collect data and track performance. . Examples of indicators to be monitored include ( but not limited to):
- LOS reports
- Denial reports
- Inpatient to Observation conversion reports
- Review Department performance metrics and personal performance. Performance metrics to include but not limited to: clinical denials, clinical denial backlog, outcome of clinical denials, timely admission and concurrent reviews
- Support the Case Management Director in maintaining the financial and clinical outcomes of the Care Coordination Department.
- Support the Steward Physician network by coordinating with the Steward ambulatory/community case managers to ensure patient information is communicated and transitions of care are in place.
- Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
- Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
- Identify service needs, systems issues and opportunities for improvement for the Department
- Review out-of-network referrals and scheduled procedures in order to manage the financial and utilization management of managed care contracts.
- Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
- Report deviations in quality care to the Director of Case Management
- Assist with the development of clinical guidelines as needed.
- Maintain current knowledge of regulatory requirements including payer and reporting requirements
- Demonstrate effective leadership skill
- Attend monthly staff meetings
- Complete all Code 44 documentation when appropriate
REQUIRED KNOWLEDGE & SKILLS:
- Strong understanding of managed care
- Sound clinical judgment
- Excellent function development and management skills
- Excellent communication and negotiation skills
- Relationship manager - providers, committees, payers
- Strong organizational skills
Education: Bachelor of Nursing Degree
Experience: At least 3 to 5 years of case management and managed care experience
Certification/Licensure: Current Massachusetts license in nursing. Certification in Case Management Preferred