Nurse Risk Manager Jobs in Pawtucket, RI (NOW HIRING)

The RN Care Manager performs utilization management, case management and discharge planning activities for acute care, and/or extended care patients including ambulatory and emergency department patients. The RN Care Manager works with the patient health care teams to assess patients transition/discharge planning needs, actively prevent unnecessary admissions/readmissions, and facilitate timely transitions/discharges.

1. Per the hospital Utilization Management Plan, the RN CM performs utilization and resource management by assessing and reassessing the patients' medical necessity to ensure accurate status (i.e. inpatient, observation, or ambulatory care) and documents the timely, appropriate use of evidence-based criteria, e.g. InterQual.

2. Responds to all insurer requests for information and collaborates with onsite review nurses e.g. regarding insurance authorization. Conducts medical record review for level of care (LOC)/disposition planning. Reassesses LOC timely to ensure appropriateness. Discusses LOC and medical necessity with attending physician daily.

3. Communicates to patient and/or patient's families, e.g. medical necessity, goal length of stay, projected discharge date. Identifies, actively intervenes escalation of system delays for secondary review, and provider-related delays for secondary medical review (i.e. physician advisor, or Chief Medical Officer) and tracks delays e.g. potential or actual avoidable days. Proactively identifies patients readiness to transition and intervenes timely, e.g. downgrade, or discharge to a post-acute care. Screen surgical procedures for medical necessity, e.g. SIMS plus.

4. Demonstrates compliance with all Federal and State regulations as it pertains to LOC assignment and medical necessity, e.g. Two-Midnight Rule and certification.

5. Proactively manages denials and third party payer reimbursement from preadmission through post-discharge in collaboration with the Patient Financial Services Department (PFS). May execute/delegate patient notices, e.g. HINN, Condition Code 44, Important Message from Medicare, Detailed Notice of Discharge, patient liability, etc. Acts as a resource to PFS, e.g. uninsured patients accessing Health Care insurance. Conducts real time follow-up on concurrent payer denials, e.g. facilitates peer to peer discussions, and completes Medicare short stay reviews and collaborates with appeals representatives.

6. Performs timely patient and family assessments to predict the patient's risk of readmissions, discharge planning needs and family/significant other health literacy, e.g. in the Emergency Department, within 24 hours of a direct admission, or pre-admission when planned, elective surgery. Fosters patient flow and throughput by coordinating patients' transition through the hospital via strategic activities to manage length of stay, cost of care and optimize each hospital day. With the patient care team, assesses patients teaching needs for a safe care transition to the next care setting. Completes interventions prior to e.g. emergency department and during hospitalization, coordinates the patient's overall discharge/transition plan with the patient health care team. Proactively initiates patient referrals, e.g. social services.

7. Facilitates and participates in daily collaborative care rounds, and assures all members of the team know patients goal length of stay (GLOS), projected discharge date, plan for disposition and risk for readmission.

8. Coordinates key interventions among members of the interdisciplinary care team, ensuring patient care is provided in a timely manner. Participates in the hospital based patient flow efforts/teams.

9. Develops and documents specific treatment plan, documents and discusses with the patient care team and assures patient's understanding of his or her role with managing disease process. Identifies/recommends modifications to the plan to help ensure a successful discharge/transition. Assures patient is discharged/transitioned to the appropriate level of care that is agreeable to the patient/family or guardian, etc. Assures that patients with identified risk for readmission have appropriate services arranged. Refers patients to establish care with a primary care provider. Refers patient/family to primary care or specialist providers for follow-up. Identifies potential barriers patients may experience with transition, and works actively to prevent barriers and facilitate timely care and transition planning. Discusses care requirements, and assures documentation is provided for the post discharge/transition care setting, e.g. concerning patient's risk for readmission and pertinent discharge/transition information. Initiates timely referrals to post-acute care providers, e.g. home health agencies, skilled nursing facilities, long-term care hospitals, acute rehabilitation facilities, assisted living facilities, homeless shelters, etc.

10. Coordinates patient care conferences, e.g. patients readmitted within thirty days of discharge, or patients who have exceeded thirty days of stay.

11. Identifies and recommends opportunities for improving quality and customer service, and actively participates in performance improvement activities. Participates in peer review/audit, and periodic interrater reliability evaluations, e.g. competency assessments and subsequent coaching. Develops a plan for attaining professional development goals e.g. set during performance review.

12. Identifies patients with complex care needs. Collaborates in the development, notification and maintenance of complex care plans. Actively participates in problem-solving activities.

13. Actively participates in internal and external committees, and projects especially those that address quality, patient flow, LOS and revenue e.g. UR Committee, Long LOS, ICD 10, Patient Financial Services, Crimson and Patient Throughput Team.

14. Ensure patients follow-up appointments, e.g. primary care provider and/or specialist provider. Completes (or delegates) follow up phone call per program requirements e.g. patients released from the Emergency Department, or discharged home, or elsewhere.

15. Demonstrates a high degree of personal courtesy and integrity when communicating with (or about) co-workers, patients and the public as outlined in the hospitals Standards of Performance policy that reflects individual dignity, respect and concern with valuing diversity and addressing age-related cultural or linguistic factors.

16. Maintains patient confidentiality at all times.

17. Performs all other related duties as assigned.

Graduate of an accredited school of nursing with an active, unrestricted Rhode Island RN license. Bachelor's degree in nursing strongly preferred, masters in health related field preferred. Minimum of 2 years of recent acute care experience. Demonstrates recent knowledge of case management, utilization review, quality assurance and third party payer regulations. Experience must demonstrate high level of interpersonal skills, both oral and written, analytical skills, leadership abilities and effectiveness with a team environment. Certification in case management e.g. CCM or ACM or obtained within 24 months of employment, pro-rated for part-time staff. As of November 1, 2015 existing staff in the role must show proof of CCM or ACM certification by November 1, 2017. Self-motivation. Commitment to continuing education and professional development. Membership and active participation in a professional organization desirable, e.g. CMSA, ACMA. Knowledge of community resources highly desirable

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation's top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.

Americans with Disability Act Statement : External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement : Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement : Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.