Utilizing a collaborative process, the case manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. The case manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. This case manager is dedicated to handle the increased volume and to support the overall case management process and the department.

• The RNs assigned will provide case management intervention on behalf of individuals who are scheduled for surgical procedures. In collaboration with the care team, the case manager ensures the patients progress through the system in an efficient and cost effective manner. The Case Manager remains involved in the patients care from scheduling of surgery, admission and during the evaluation phase of discharge planning and will make recommendations for the discharge plan based on the assessment. The Case manager serves as a resource for utilization management, i.e., level of care and assignment of appropriate status before admission, in the PPC and the post-surgical areas.

• • Graduate of an accredited BS program in Nursing preferred.
  • Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.
  • A minimum of 3-5 years recent clinical experience required, and 1-3 years of recent acute, Inpatient Case Management experience required.
  • Ability to understand confidentiality and the legal and ethical issues pertaining to patient health; understand medical terminology, how to obtain an accurate history; establish treatment goals; establish working relationships with referral sources; develop treatment plans.
  • Knowledge and understanding of methods for assessing an individual's level of physical/mental impairment; understand the physical and psychological characteristics of illness; ability to assist individuals with the development of short- and long-term health goals.
  • Ability to understand the requirements for prior approval by payer; be able to evaluate the quality of necessary medical services; be able to acquire and analyze the cost of care; understand the various health care delivery systems and payer plan contracts; be able to demonstrate cost savings.
  • Ability to understand case management philosophy and principles; apply problem solving techniques to the care management process; document care management services; understand liability issues for care management activities.
  • Knowledgeable on how to access and evaluate the available resources to meet a client's needs; able to develop new resources.
  • Excellent interpersonal, verbal, and written communication and negotiation skills
  • Strong analytical, data management and PC skills.
  • Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Understanding of pre-acute and post-acute venues of care and post-acute community resources.
  • Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.
  • Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.

NursingCM
Req id: 26964