Job description

Location: CHA Cambridge Hospital
Work Days: 36 hours/week
Category: Registered Nurse
Department: Inpatient Case Management CH
Job Type: Full time
Work Shift: Days
Hours/Week: 36.00
Union: Yes
Union Name: MNA Cambridge
Under the general supervision of the Director of Care Management, the RN Case Manager provides clinically-based case management to support the delivery of effective and efficient patient care consistent with the Centers for Medicaid and Medicare Conditions of Participation. The RN Case Manager will collaborate with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilize criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, create a post-acute care plan appropriate to the patient's needs and resources and facilitate this transition in concert with that patient's inpatient and post-acute care teams.
Duties/Responsibilities

• Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria (i.e.- Interqual) to identify needs related to utilization management and post-acute care planning.
• Based on input and direction from the multi-disciplinary team, facilitate safe and appropriate post-acute care services integrating patient and family preferences.
• Conduct accurate concurrent reviews using InterQual criteria; initiate payer contact, and communicate clinical review data to relevant parties.
• Perform a comprehensive review of the medical record to ensure documentation of appropriate level of care status.
• Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
• Refers appropriate cases to social work team members based on established referral criteria.
• On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient's physician to resolve the issue. Refers unresolved cases to the Director of Care Management and the Associate Medical Director of Utilization Management in a timely manner.
• Identifies high-risk patients to promote coordination of services and to prevent avoidable readmission and/or Emergency Department visits.
• Educates staff and physicians about CMS requirements and the Conditions of Participation (CoP).
• Captures and trends practice, systems, operations, and patient/family issues that result in potentially avoidable days.
• Performs other duties as assigned.

Qualifications/Experience
Education: Bachelor of Science in Nursing (BSN) degree preferred.
Licensure and Certifications: Current Massachusetts RN license. Certification in Case Management preferred. Current American Heart Association Basic Life Support (BLS) Certification required.
Experience: Hospital Care Management Experience strongly preferred. 3-5 years of medical/surgical RN experience OR 3-5 years of other RN Case Management experience is required.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.

Cambridge Health Alliance brings Care to the People - including your neighbors, friends and family. Our local hospitals and care centers serve our vibrant, diverse communities, and play an integral role in improving health. As passionate advocates for the underserved, we actively partner with our communities to take on challenging public health issues, and conduct important research to help reduce barriers to care. We believe that everyone deserves access to high quality, convenient health care. This is why our employees believe in where they work and why many build long, rewarding careers at CHA.

Healthcare is changing rapidly. CHA has a strategic plan that charts a proactive course for our future. It is built on a vision of equity and excellence for everyone, every time. It also recognizes that our workforce is our most valuable asset and prioritizes competitive salaries, benefits and professional development opportunities for employees. The strategic plan is changing the way we provide care and improving the health and experience of our patients; we are looking for smart, committed, compassionate people who want to be part of making our vision of better health and equity a reality.

At CHA, you can believe in where you work and go home every day knowing you made a difference. Join our team and help us bring Care to the People.

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