Job ID R5449 Full / Part Time:Part time
Full / Part Time:Part time
This is a 32 hour per week position, every other weekend, every other holiday
Hours 9am-5:30pm, located in Greenfield, MA.
The Hospital Case Manager is a registered professional nurse who facilitates and enhances collaboration with patients, families, physicians and healthcare providers to ensure patients receive the services required to improve healthcare outcomes and quality of life. The Hospital Case Manager seeks to assure that quality care is provided to patients and is an active participant in the process to improve operational efficiency and patient outcomes.
The Hospital Case Manager participates in the implementation of a patient-centered plan of care. Coordinates input from all health care professionals, conducts assessments of patient and family needs and facilitates and documents the discharge plan, assuring continuity of care. Identifies and contributes to modifications in nurse and physician practice patterns, utilizing case management tools, to achieve quality of care, patient satisfaction, and appropriate use of resources, in alignment with medical management initiatives and product line goals. Evaluates appropriateness of admissions and continued stay using approved criteria. Collaborates with payers through ongoing written and verbal communication to optimize the reimbursement potential for Franklin Medical Center. Adhere to system and department compliance policies, and any applicable laws and regulations. Provides case management coverage 7 days a week.
1) Uses Case Management skills to ensure quality patient centered care is achieved. Assists and supports development of case management program. Utilizes effective communication with peers, patients and families. Performs daily review of cases and makes appropriate recommendations to the care team for practice guideline utilization, LOS, and quality of care. Recognizes the case manager role in assessing, facilitating, collaborating and coordinating patient services through the continuum of care. Effectively collaborates with others on the healthcare team to resolve patient care issues. Applies utilization criteria correctly and responsibly to best portray the process of care delivery at FMC. Identifies appropriateness of admission and concurrent days of stay. Provides verbal and written notices of non-coverage to patients and/or their representatives, in accordance with departmental policies and third party regulations.
2) Communicates effectively and efficiently with insurance companies to avoid the denial/appeal process whenever possible. Understands the role of the Physician Advisor for Case Management and makes appropriate referrals for review. Provides a clear and concise review. Keeps Manager informed on issues of prolonged LOS, patient/family concerns and insurance payment issues.
3) Participates in the Quality Management Initiatives. Identifies and obtains necessary information for potential nosocomial infections. Obtains necessary data for current quality improvement screens. Demonstrates appropriate knowledge as to what should be reported to the Quality Management/Risk Management programs. Shows appropriate confidentiality practice.
4) Provides post acute hospital care planning/discharge facilitation. Proactively works with the healthcare team to identify those patients who will need some level of care following their acute hospitalization. Serves as an educator and mentor to others on the healthcare team on the process of post acute care planning. Involves patients/families in the discharge planning process to facilitate a clear understanding by all parties. Monitors each patient's discharge plan of care for variance and makes appropriate recommendations and revises the plan as necessary. Assures that interventions are in alignment with medical management initiatives. Provides appropriate financial information to patients and/or families including scope of reimbursement sources. Follows all state and federal guidelines in regards to patient rights in planning for their post acute needs.
5) Collaborates and negotiates with insurance providers and community agencies/facilities to see that an optimal plan is arranged for the patient. Respects and honors patient's/family's strengths, values and cultural/spiritual preferences. Provides timely documentation of the post acute care plan in the medical record. Uses CIS and Midas as a tool for multidisciplinary communication.
6) Contributes to Day-To-Day Functioning of the Department. Demonstrates the ability to recognize and act on priorities promptly. Willingly adjusts schedule to needs of department and co-workers. Smoothly adjusts schedule to needs of department and co-workers. Assists in maintaining departmental manuals as requested, to reflect current procedures and utilization requirements. Responds to questions and inquires from public and employees in a courteous and pleasant manner. Identifies areas for improvement in departmental and hospital functions and communicates suggestions to manager. Manages special projects as requested by manager.
7) Demonstrates strong clinical knowledge as part of the healthcare team to ensure quality, evidenced based care is delivered. Demonstrates strong clinical knowledge in the patient population being managed. Continually seeks to develop their body of clinical knowledge. Serves as a resource to members of the healthcare team.
8) Assumes Responsibility for Own Professional Growth. Attends educational programs to maintain current knowledge in utilization management, discharge planning, and case management with specific emphasis on own areas of responsibility. Attends educational program to maintain knowledge of current clinical management of patient problems on assigned clinical areas. Establishes annual goals for professional growth and seeks opportunities that lead to the accomplishment of these goals. Attends regularly scheduled departmental meetings.Required Work Experience:
1) Minimum 3 years recent acute medical-surgical nursing experiencePreferred Work Experience:
1) 1-3 years Case ManagementSkills and Competencies:
1) Requires a working knowledge of community resources and Utilization/Quality Review standards and activities conducted by third party payers
2) Ability to organize and prioritize workload in order to meet deadlines
3) Must possess excellent interpersonal skills in order to interact with all levels of health care providers, support staff, and third party payers where appropriate
Education:Bachelor of Science (Required)
Certifications:Registered Nurse - State of Massachusetts
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
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