Insurance Case Manager Jobs in Quincy, MA (NOW HIRING)

Job Description Summary

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. The Case Manager is on-site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.
Job Description

1 - The RN Case Manager is responsible for reviewing the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
a - Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
b - Identifies cases daily that fail to meet criteria and refers these cases to appropriate manager or physician advisor for secondary review.
c - Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity
d - Contacts the attending physician to notify him/her of decision to issue notice of non-coverage. Explains UR process and insurance coverage requirements. Obtains physician written concurrence when necessary; e.g., Medicare patients.
Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission. Issues the termination letter for the Medicare patient
e - Reinstates insurance coverage when patient condition becomes acute and meets criteria again. Issues reinstatement letter.
f - Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payor/insurance guidelines.
g - Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
h - Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/guidelines.
2 - Plays an essential role in assisting physicians, nursing and staff with accurate determination of a patient's observation status. The RN Case Manager is an important resource in preventing delayed discharges of observation patients.
a - Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
b - Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient. Refers the questionable status to internal physician advisor or EHR according to the Departmental Process.
c - Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the level of care, utilizing InterQual for Observation.
d - Works with physicians, nursing and staff, patients and families to arrange prompt and safe discharge
e - RN Case Manager must take telephone orders from physicians changing patient status from observation to inpatient admission. This should be done when monitoring observation status. A call or page should be made to physician if the RN Case Manager believes that this should be an inpatient admission and not wait until the 24 hours are ending before conversion. RN Case Manager must actively monitor patients on observation status and seek to clarify their status as close to the 24-hour benchmark as possible. The RN Case manager must send a concern in a timely fashion to facilitate the patient being put into the correct patient status and to provide timely notification.
3 - Participates in case finding and pre-admission evaluation screening to assure reimbursement.
a - Identifies potential transition planning problems in a timely manner to set up services required.
b - Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals; e.g., SNF/VNA/Home Pharmacy
c - Identifies need for new resources if gaps exist in service continuum, and initiates creative care delivery options.
4 - The RN Case Manager is responsible for assessing patient acute level of care needs and works to implement and coordinate interventions aimed at facilitating a safe and timely discharge plan to the appropriate sub-acute settings in collaboration with the Case Manager Specialist.
a - With the Case Manager, work to identify, and prioritize workflow through identification of patient specific, department needs and or unit based needs.
b - Executes and implements a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
c - Makes and documents appropriate changes to discharge plan when necessary.
d - Proactively uncovers barriers to early/timely discharge and overcomes them.
e - Facilitates and coordinates patient care rounds.
f - Conducts necessary conferences and team meetings regarding specific patient needs.
g - Implements interventions that lead to patient accomplishing goals established in Plan.
h - Coordinates the necessary resources to accomplish goals developed in Plan.
i - Proactively affects system to facilitate efficient flow of care, anticipates discharge process.
j - Gathers information from multidisciplinary team and monitors appropriate discharge plan.
5 - Continued.
a - Uses and Updates the interdisciplinary patient White Board for communication enhancement; including RN Case Manager name, time/date/plan for discharge.
b - Issues the Medicare Important Message (IM).
c - Proper use of the Medical Necessity form for post discharge transportation.
d - Use of technical tools, i.e., eDischarge, EHR, Interqual, MCCM
e - Identifies and / or facilitates establishment of a patient's Health Care Proxy.p)
f - Identifies patient Care Plan Partner.
g - Fosters patient and family awareness of Patient Portal.
6 - Ensure that patient has received all information related to choice of follow-up care facilities according to patient and family preference and any ACO preferred contracted providers.
a - Ensure that, at minimum, 3 referrals are processed for continuum of care providers
b - Document choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record.
c - Expedite and process referrals, in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.
d - Document response by providers.
e - Delivers the Medicare Important Message (IM) per department protocol.
f - Have patient, family/healthcare Proxy sign discharge plan.
7 - Interacts, communicates, and intervenes with multi-disciplinary healthcare team in a purposeful, goal-directed fashion. Works pro-actively and utilizes critical thinking skills to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization, discharge planning.
a - Establishes a means of communicating and collaborating with physicians, other team members, the patient's payers, and administrators.
b - Explores strategies to reduce length of stay and resource consumption within the care managed patient populations, implements them and documents the results.
c - Communicates to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits, facilitates discharge plan
d - Maintains a pro-active role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement
e - Reviews physician documentation and follows procedures to seek clarification where indicated of that documentation relative to diagnosis and comment on the patient's clinical state.
f - Coordinate and participate in daily multidisciplinary patient care rounds.
g - Uses the SBAR method to communicate with MD, and peers
h - Acts as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning the more clinically complex or long length of stay patient.
8 - Establishes and maintains effective communication with all referral sources, insurers, vendors and patient supplier systems.
9 - Maintains consistently a professional commitment to institutions and department's goals and objectives. Demonstrates flexibility to the department's needs in relation to floor and work schedule, and any other internal and external demands on the department. Continually shows commitment to the Department by extending self when need arises.
10 - Maintains an updated knowledge base of and references resources outlining provider benefits for care choices, including public, private, and governmental payers and established / preferred ACO relations
a - Maintains a working knowledge of the requirements of the payers most frequently seen with the patient population.
b - Maintains a working knowledge of the resources available in the community for patients/families.
c - Maintains current nursing licensure CEU credits, case management certification CEU's.
d - Maintains Interqual Certification.
11 - Is responsible for department operational excellence, regarding safe and effective discharge planning; assures department delivers quality services in accordance with applicable policies, procedures and professional standards.
a - Manages all activities so that quality services are provided in an efficient and effective manner.
b - Services provided meet all applicable regulatory requirements
c - Participates in departmental and organizational Quality Improvement initiatives involving the Lean principles and TIM WOODS.
d - Maintains departmental productivity measurements.
e - Has an awareness of departmental productivity measurements including LOS and utilization
f - Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements
12 - Attains all agreed to goals and objectives within specified time frames, as part of the organization's overall mission.
13 - Technology - Embraces technological solutions to work processes and practices.
a - eDischarge, EHR, Interqual, MCCM, Epic, Workday
JOB REQUIREMENTS
Minimum Education - Preferred
Registered Nurse, Bachelors prepared strongly preferred
Minimum Work Experience
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
Required Licenses / Registrations
RN - Registered Nurse
Required Certifications
ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire.
Required additional Knowledge, and Abilities
Demonstrated skills in the areas of: 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.