RN Case Manager (Per Diem)

Position: RN Case Manager       

Department: Care Management

Schedule: Part Time, Per Diem

POSITION SUMMARY:

The RN Case Manager (CM) is responsible for overseeing the appropriate level of care and collaborates with the Social Work partner regarding discharge planning with a particular focus on medically complex discharge planning. The RN CM will be assigned to selected areas of the Hospital based upon department staffing and coverage. The RN CM will collaborate with SW Care Coordinator as a team to meet the needs of the patients within unit assigned. As this is an evolving position, duties and responsibilities may vary based on specific assignments and additional tasks may be added as the position is further developed.

Each staff member will participate in a departmental orientation focused on Case Management Standards of Practice. All staff will be cross-trained and oriented to the ED Case Management Practice.

ESSENTIAL RESPONSIBILITIES / DUTIES:

UM Reviews and Denial Support 

• Perform Interqual Admission Assessments on all new admissions and forward the reviews to insurers as needed. Answer questions from the insurers and continue to provide any additional clinical information they request. Timely reviews to be provided so payers have sufficient time to review case and respond quickly. 
• Communicate in real time with physicians on any patients not meeting criteria and establish a course of action. Work collaboratively with the MDs to help them understand documentation issues or any leveling issues. Inform physician partners on Inpatient vs. Observation criteria or acute care criteria. 
• 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 daily InterQual reviews on assigned patients and document when InterQual criteria is not met. Forward all reviews to insurers on a timely basis. Answer any questions from insurers. Perform concurrent denial management to resolve issues and ensure authorizations prior to discharge of patient. Inform Directors /designee regarding outcome.  
• Upon receipt of admitting or daily denials from insurers, review the case and provide the insurer with additional clinical information for the insurers' reconsideration. 
• Complete the clinical record and patient profile in Allscripts or a BMCHS-designated software tool. Utilize the Allscripts tool appropriately so all fields are complete, all clinical information is fully recorded , all changes to a patient's clinical condition are recorded, all interaction with insurers, RNs, MDs is documented, as appropriate. 
• Copy the Allscripts clinical information and place in medical record, as appropriate. 
• Finalize authorization for stay for all covered days prior to case closure.  •

 Discharge Planning and Execution: 

•  Review initial Admission Assessments and proposed discharge plans outlined by the SW Care Coordinator. Collaborate with SW Care Coordinator on discharge plan. Identify the patients/discharges that may be complicated and review these discharges with the Social Worker. 
• Coordinate and monitor discharge planning activities for an assigned patient population and provide support as needed to the SW Care Coordinator and administrative staff managing the discharge process. 
• Collaborate with the Interdisciplinary team to create an individualized discharge plan for high-risk patients, as needed, ensuring appropriate level of services are scheduled for the patient. 
• Inform PCPs, attending physicians and clinical staff on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives in collaboration with SW Care Coordinators. 
• Communicate pertinent patient information, on an as needed basis, 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. 
• Be aware of disease management programs and services in existence within BMCHS to use network resources, as appropriate.

Boston Medical Center South: 

• Provide patient education and family teaching, on an as needed basis. 
• Act as an advocate for the patient. 
• Facilitate/coordinate multidisciplinary rounds on assigned patient care units, at a minimum of Monday - Friday. 
• Attend UMCM meetings as appropriate 

 Other Responsibilities:

• Maintain daily tracking tools to support data reporting, including but not limited to the following list: 
• Avoidable