Case Manager, Util. Mgmt. ED/EDOU

The Utilization Management (UM) Case Manager as a member of the health care team, collaborates to enhance the delivery of patient care services along the continuum of care. The UM Case Manager ensures the appropriate level of care determination for each patient. This nurse helps to ensure the institutional standards of high-quality patient care, reducing cost and ensuring reimbursement. Through broad knowledge of clinical care and systems management, the case manager evaluates, predicts, and facilitates the trajectory of patient care for appropriate admission classification and continued stay authorizations.

• Maintains strict adherence and maintains professional competency by keeping abreast of Medicare, MassHealth, and third-party payers regulatory and compliance requirements

* Documents in the medical record as appropriate, as part of the Interdisciplinary team in accordance with the MGH Case Management Documentation standards

* Utilize a translator when appropriate and incorporate awareness of patient's cultural needs that may impact the plan of care

• Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused and friendly, high quality, efficient, and cost effective
• In collaboration with multidisciplinary team, monitors the patient's progress and plan of care with the aid of internal and external utilization and quality guidelines. Identifies, documents, and reports issues and system barriers
• Complies with Case Management Standards of Practice, based on assignment
• Evaluates, coordinates, manages and documents all activities related to clinical approval/denial processes and communicates relevant information to patients/families, members of the multidisciplinary team, hospital departments, and payers
• Performs appropriate Level of Care (LOC) determinations based on severity of illness and intensity of service using InterQual Criteria (IQ) (observation, inpatient, PPR)
• Monitors appropriate length of stay and ensures patient needs are met while collaborating with payers to facilitate next LOC if appropriate
• Monitors appropriate length of stay with consideration for patient safety and in consultation with the treating team.
• Monitors and tracks potentially avoidable days
• Collaborates with team to ensure patient benefits are adhered to and are within the scope of coverage for planning patient needs at discharge
• Communicates with Patient Financial Services (PFS) to assist and support patient with insurance coverage
• Coverage on weekends and holidays as per Case Management policy
• Performs other duties as assigned

MA RN License Required

Minimum 2 years of RN experience in Medical/Surgical environment, Case Management experience preferred

• Acute hospital experience preferred
• Strong assessment and problem solving skills
• Strong interpersonal skills
• Ability to work independently with minimal supervision
• Goal oriented and accountable
• Demonstrated organizational skills
• Demonstrated ability to work in a complex setting
• Ability to work in an interdisciplinary team based environment
• Strong oral and written communication skills
• CM Certification preferred

Computer experience preferred

Massachusetts General Hospital is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.