South Shore Health
Under the general supervision of the Case Management Manager, the RN Case Manager acts as a patient advocate and case manager to SSH&EC clients. This autonomous role coordinates, negotiates, procures services, and resources, and manages the complex care of patients to achieve quality, cost‑efficient outcomes. It applies review criteria to determine medical necessity for admission and continued stay, provides clinically based case management, discharge planning, and care coordination, and collaborates with interdisciplinary staff internal and external to the organization. The RN Case Manager participates in quality improvement and evaluation processes related to patient care management.
Location: 55 Fogg Road, Weymouth, MA 02190 (Facility: LOC0001 – 55 Fogg Road)
Department: SSH Care Progression
Shift: Day (United States of America)
Work Schedule: 4 days of 10‑hour shifts or 5 days of 8‑hour shifts, with weekend and holiday rotation required. The RN Case Manager is available on‑site seven (7) days a week, including holidays, and must attend weekend and occasional holiday shifts.
Compensation: $117,707.20 – $170,768.00 per year.
Responsibilities
The RN Case Manager is responsible for reviewing the medical record of all observation and inpatient admissions
a – Use InterQual, physician certification, and payor criteria to assist the physician in determining medical necessity for observation, admission, and continued stays.
b – Identify cases daily that fail to meet criteria and refer these to an appropriate manager or physician advisor for secondary review.
c – Contact attending physicians daily about cases lacking adequate documentation to support medical necessity.
d – Notify physicians of non‑coverage decisions, explain the UR process, obtain physician written concurrence when needed, and inform patients or next of kin when coverage is terminated.
e – Re‑establish insurance coverage when patient condition becomes acute again, issuing reinstatement letters.
f – Continue the review of all patients using criteria and determine the need for continued hospitalization based on third‑party payor guidelines.
g – Provide clinical data/information to contracted third‑party payers within 24 hours of request to avoid reimbursement delays.
Plays an essential role in assisting physicians, nursing, and staff with accurate determination of a patient’s observation status
a – Identify and review observation patients to determine correct patient level of care daily prior to 12 PM.
b – Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status, referring questionable status to internal physician advisor or EHR per departmental process.
c – Serve as review coordinator for observation services; review medical record for appropriateness of status and level of care and facilitate the level of care using InterQual for Observation.
d – Work with physicians, nursing, staff, patients and families to arrange prompt and safe discharge.
e – Take telephone orders from physicians changing patient status from observation to inpatient admission promptly and communicate with physicians as needed.
Participates in case‑finding and pre‑admission evaluation screening to assure reimbursement
a – Identify potential transition planning problems early to set up required services.
b – Work with attending physicians to move patients through the SSH&EC system and arrange appropriate services or referrals (e.g., SNF, VNA, Home Pharmacy).
c – Identify need for new resources if gaps exist and initiate creative care delivery options.
The RN Case Manager is responsible for assessing patient acute level of care needs and coordinating interventions to facilitate a safe and timely discharge plan
a – Identify, prioritize, and execute workflow with the Case Manager Specialist.
b – Implement a safe and effective discharge plan per the case management assessment and Conditions of Participation.
c – Document changes to the discharge plan as necessary.
d – Proactively uncover barriers to early discharge and overcome them.
e – Facilitate and coordinate patient care rounds.
f – Conduct necessary conferences and team meetings regarding specific patient needs.
g – Implement interventions that lead to patient accomplishment of goals established in the Plan.
h – Coordinate the necessary resources to accomplish plan goals.
i – Proactively affect system flow to facilitate efficient care and anticipate discharge processes.
j – Gather information from multidisciplinary team and monitor appropriate discharge plan.
Continued responsibilities
a – Use and update the interdisciplinary patient White Board for communication enhancement.
b – Issue the Medicare Important Message (IM).
c – Properly use the Medical Necessity form for post‑discharge transportation.
d – Utilize technical tools such as eDischarge, EHR, InterQual, MCCM.
e – Facilitate the establishment of a patient’s Health Care Proxy.
f – Identify patient Care Plan Partner.
g – Foster patient and family awareness of the Patient Portal.
Ensure patient receives all information related to choice of follow‑up care facilities
a – At a minimum, process three referrals for continuum of care providers.
b – Document choices provided, noting ACO relationships and patient/family selections.
c – Expedite and process referrals in a timely manner per departmental standards.
d – Document provider responses.
e – Deliver the Medicare Important Message per protocol.
f – Obtain patient, family or healthcare proxy signature on discharge plan.
Interact, communicate, and intervene with a multidisciplinary team in a goal‑directed fashion
a – Establish effective communication with physicians, team members, payers, and administrators.
b – Explore strategies to reduce length of stay and resource consumption, implement and document results.
c – Communicate with appropriate members of the healthcare team when patients risk loss of insurance coverage.
d – Maintain proactive documentation to minimize inefficient resource use and prevent loss of reimbursement.
e – Review physician documentation; seek clarification where needed.
f – Coordinate and participate in daily multidisciplinary patient care rounds.
g – Use the SBAR method to communicate with MD and peers.
h – Act as a clinical resource supporting the Case Manager Specialist for complex or long‑stay patients.
Establish and maintain effective communication with all referral sources, insurers, vendors and patient supplier systems
Maintain a professional commitment to institutional and departmental goals and objectives
Demonstrate flexibility in floor and work schedule, and respond to internal and external demands.
Extend oneself when needed to support the Department.
Maintain an updated knowledge base of provider benefits and resources
a – Maintain working knowledge of frequently seen payers.
b – Maintain knowledge of community resources available to patients/families.
c – Keep current nursing licensure CEU credits and case management certification CEUs.
d – Maintain InterQual Certification.
Assume responsibility for department operational excellence regarding safe and effective discharge planning
a – Manage all activities to ensure efficient and effective quality services.
b – Ensure services meet all applicable regulatory requirements.
c – Participate in departmental and organizational quality improvement initiatives (Lean principles and TIM WOODS).
d – Maintain departmental productivity measurements.
e – Develop awareness of departmental productivity measurements including LOS and utilization.
f – Follow department policies, procedures, and standards of care that support operational excellence.
Attain all agreed goals and objectives within specified time frames
Embrace technological solutions to improve processes and practices
a – Utilize eDischarge, EHR, InterQual, MCCM, Epic, Workday.
Qualifications
Minimum Education
– Registered Nurse (RN) with a bachelor’s degree strongly preferred.
Minimum Work Experience
– 3‑5 years acute care hospital experience; critical care or emergency department experience highly desirable.
Licenses / Registrations
– RN license (Massachusetts).
Certifications (required)
– Accredited Case Manager (ACM) or Certified Case Manager (CCM) within two years of hire.
Skills and Abilities
– Demonstrated skills in negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, and multitasking in high‑stress environments.
Knowledge
– Healthcare financing, community and organizational resources, patient care processes, data analysis, utilization management for third‑party payers, post‑acute care community resources.
Experience with Managed Care is preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility and ability to adapt to changing priorities and regulations.
Availability: Monday‑Friday with weekend/holiday rotation required.
Job Title: RN Case Manager – SSH&EC
Employment Type: Full‑time
Seniority Level: Entry level
Location: 55 Fogg Road, Weymouth, MA 02190
Only for existing employees: Please apply through the internal career site. Active upon posting.
#J-18808-Ljbffr
Location: 55 Fogg Road, Weymouth, MA 02190 (Facility: LOC0001 – 55 Fogg Road)
Department: SSH Care Progression
Shift: Day (United States of America)
Work Schedule: 4 days of 10‑hour shifts or 5 days of 8‑hour shifts, with weekend and holiday rotation required. The RN Case Manager is available on‑site seven (7) days a week, including holidays, and must attend weekend and occasional holiday shifts.
Compensation: $117,707.20 – $170,768.00 per year.
Responsibilities
The RN Case Manager is responsible for reviewing the medical record of all observation and inpatient admissions
a – Use InterQual, physician certification, and payor criteria to assist the physician in determining medical necessity for observation, admission, and continued stays.
b – Identify cases daily that fail to meet criteria and refer these to an appropriate manager or physician advisor for secondary review.
c – Contact attending physicians daily about cases lacking adequate documentation to support medical necessity.
d – Notify physicians of non‑coverage decisions, explain the UR process, obtain physician written concurrence when needed, and inform patients or next of kin when coverage is terminated.
e – Re‑establish insurance coverage when patient condition becomes acute again, issuing reinstatement letters.
f – Continue the review of all patients using criteria and determine the need for continued hospitalization based on third‑party payor guidelines.
g – Provide clinical data/information to contracted third‑party payers within 24 hours of request to avoid reimbursement delays.
Plays an essential role in assisting physicians, nursing, and staff with accurate determination of a patient’s observation status
a – Identify and review observation patients to determine correct patient level of care daily prior to 12 PM.
b – Consult with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status, referring questionable status to internal physician advisor or EHR per departmental process.
c – Serve as review coordinator for observation services; review medical record for appropriateness of status and level of care and facilitate the level of care using InterQual for Observation.
d – Work with physicians, nursing, staff, patients and families to arrange prompt and safe discharge.
e – Take telephone orders from physicians changing patient status from observation to inpatient admission promptly and communicate with physicians as needed.
Participates in case‑finding and pre‑admission evaluation screening to assure reimbursement
a – Identify potential transition planning problems early to set up required services.
b – Work with attending physicians to move patients through the SSH&EC system and arrange appropriate services or referrals (e.g., SNF, VNA, Home Pharmacy).
c – Identify need for new resources if gaps exist and initiate creative care delivery options.
The RN Case Manager is responsible for assessing patient acute level of care needs and coordinating interventions to facilitate a safe and timely discharge plan
a – Identify, prioritize, and execute workflow with the Case Manager Specialist.
b – Implement a safe and effective discharge plan per the case management assessment and Conditions of Participation.
c – Document changes to the discharge plan as necessary.
d – Proactively uncover barriers to early discharge and overcome them.
e – Facilitate and coordinate patient care rounds.
f – Conduct necessary conferences and team meetings regarding specific patient needs.
g – Implement interventions that lead to patient accomplishment of goals established in the Plan.
h – Coordinate the necessary resources to accomplish plan goals.
i – Proactively affect system flow to facilitate efficient care and anticipate discharge processes.
j – Gather information from multidisciplinary team and monitor appropriate discharge plan.
Continued responsibilities
a – Use and update the interdisciplinary patient White Board for communication enhancement.
b – Issue the Medicare Important Message (IM).
c – Properly use the Medical Necessity form for post‑discharge transportation.
d – Utilize technical tools such as eDischarge, EHR, InterQual, MCCM.
e – Facilitate the establishment of a patient’s Health Care Proxy.
f – Identify patient Care Plan Partner.
g – Foster patient and family awareness of the Patient Portal.
Ensure patient receives all information related to choice of follow‑up care facilities
a – At a minimum, process three referrals for continuum of care providers.
b – Document choices provided, noting ACO relationships and patient/family selections.
c – Expedite and process referrals in a timely manner per departmental standards.
d – Document provider responses.
e – Deliver the Medicare Important Message per protocol.
f – Obtain patient, family or healthcare proxy signature on discharge plan.
Interact, communicate, and intervene with a multidisciplinary team in a goal‑directed fashion
a – Establish effective communication with physicians, team members, payers, and administrators.
b – Explore strategies to reduce length of stay and resource consumption, implement and document results.
c – Communicate with appropriate members of the healthcare team when patients risk loss of insurance coverage.
d – Maintain proactive documentation to minimize inefficient resource use and prevent loss of reimbursement.
e – Review physician documentation; seek clarification where needed.
f – Coordinate and participate in daily multidisciplinary patient care rounds.
g – Use the SBAR method to communicate with MD and peers.
h – Act as a clinical resource supporting the Case Manager Specialist for complex or long‑stay patients.
Establish and maintain effective communication with all referral sources, insurers, vendors and patient supplier systems
Maintain a professional commitment to institutional and departmental goals and objectives
Demonstrate flexibility in floor and work schedule, and respond to internal and external demands.
Extend oneself when needed to support the Department.
Maintain an updated knowledge base of provider benefits and resources
a – Maintain working knowledge of frequently seen payers.
b – Maintain knowledge of community resources available to patients/families.
c – Keep current nursing licensure CEU credits and case management certification CEUs.
d – Maintain InterQual Certification.
Assume responsibility for department operational excellence regarding safe and effective discharge planning
a – Manage all activities to ensure efficient and effective quality services.
b – Ensure services meet all applicable regulatory requirements.
c – Participate in departmental and organizational quality improvement initiatives (Lean principles and TIM WOODS).
d – Maintain departmental productivity measurements.
e – Develop awareness of departmental productivity measurements including LOS and utilization.
f – Follow department policies, procedures, and standards of care that support operational excellence.
Attain all agreed goals and objectives within specified time frames
Embrace technological solutions to improve processes and practices
a – Utilize eDischarge, EHR, InterQual, MCCM, Epic, Workday.
Qualifications
Minimum Education
– Registered Nurse (RN) with a bachelor’s degree strongly preferred.
Minimum Work Experience
– 3‑5 years acute care hospital experience; critical care or emergency department experience highly desirable.
Licenses / Registrations
– RN license (Massachusetts).
Certifications (required)
– Accredited Case Manager (ACM) or Certified Case Manager (CCM) within two years of hire.
Skills and Abilities
– Demonstrated skills in negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, and multitasking in high‑stress environments.
Knowledge
– Healthcare financing, community and organizational resources, patient care processes, data analysis, utilization management for third‑party payers, post‑acute care community resources.
Experience with Managed Care is preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility and ability to adapt to changing priorities and regulations.
Availability: Monday‑Friday with weekend/holiday rotation required.
Job Title: RN Case Manager – SSH&EC
Employment Type: Full‑time
Seniority Level: Entry level
Location: 55 Fogg Road, Weymouth, MA 02190
Only for existing employees: Please apply through the internal career site. Active upon posting.
#J-18808-Ljbffr