RN Case Mgr - 40hrs -Emergency Room

Wentworth-Douglass Hospital, an affiliate of Mass General Brigham, is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.

Wentworth-Douglass Hospital remains among the nation's top hospitals for patient experience as a recipient of the Healthgrades 2023 Outstanding Patient Experience Award for the tenth consecutive year. Wentworth-Douglass Hospital is renowned as one of the largest acute care hospitals in the Seacoast region of New Hampshire and Southern Maine. At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.

1. Facilitates coordination of care for patients along the healthcare continuum.
o Meets directly with the patient/family to assess needs and develop an individualized plan in collaboration with the provider.
o Refers appropriate cases for social work interventions.
o Collaborates/communicates with external case managers.
o Initiates and facilitates referrals for home healthcare, hospice, DME and pharmacy.
o Facilitates transfer to other facilities as appropriate.
o Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
o Documents relevant discharge planning information in the medical record according to department standards.
2. Demonstrates professionalism with managed care entities and processes.
. Keeps informed of changes in contractual relationships for all payer systems.
o Provides requested information regarding patient care and services to external review and regulatory agencies.
o Coordinates/ performs all follow-up activities related to Medicare, other third-party payers, and hospital-negotiated contracts.
o Communicates to patients, MDs, and other appropriate personnel changes in review findings resulting in level of care changes or findings consistent with termination/ denial of benefits.
o Collaborates with managers & staff in the Patient Registration, Patient Accounts, and Medical Information Departments on issues of continued stay, denials, and related activities.
o Provides information/ education to patients, family members, &/or patient representatives regarding the appeals process upon receipt of Medicare termination of benefits letters or commercial denial letters.
o Informs ED Director, CFO/VP Finance and /or other management team members of situations which require notification or administrative action.
o Assists medical record coders in clarification of medical clinical documentation issues related to DRG assignment.
3. Demonstrates excellence in leadership skills and professional performance.
o Maintains close communication with ED Director/coordinator regarding utilization, quality of care, risk, and infection control issues.
o Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues applicable to Utilization Review functions.
o Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
o Educates health team colleagues about Case Management, including the role of the Case Manager and the needs of the case managed population.
o Participates in educational programs as requested &/or as appropriate.
o Collaborates with medical staff, nursing staff and ancillary staff to eliminate barriers to efficient delivery of care.
4. Collects data pertinent to care management, utilization management, and performance improvement.
. Collects and addresses variances from the clinical pathway/plan of care.
o Reports adverse drug reactions appropriately.
o Reports issues related to infection control/ surveillance.
o Assist with the collection and reporting of financial indicators, including resource utilization, readmission's, attribution delays, denials and appeals.
o Documents clinical pathway variances and outcomes which relate to area of direct responsibility in MIDAS.
o Reports data findings & any noted trends at UM Committee and to other appropriate individuals/ committees.
5. Evaluates the provision of care and the appropriate utilization of resources.
o Reviews medical records for appropriateness of admission &/or continued stay using established criteria. Documents findings based on department standards. Refers cases as needed to the physician advisor.
o Communicates utilization issues to the appropriate individuals.
o Serves as a resource to personnel in Patient Registration and Pre-Admission Services, & other staff as appropriate, regarding determination/ classification of the patient's admission status.
o Discusses cases with the attending physicians; exploring strategies to optimize resource consumption.
o Implements strategies to reduce lengths of stay when appropriate.
o Communicates with external case managers as appropriate.
o Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
o Seeks consultation from appropriate disciplines/departments as required to expedite care and determine appropriate plan.

Experience Minimum Required

* 2 or more years, Med/Surg, Long Term Acute Care or like field, required.

Experience Preferred/Desired

* Prior Homecare, Emergency Department or ICU experience desired.

Education Minimum Required

* Current and valid RN license.

Education Preferred/Desired

* BSN, Case Manager Certification

Training Minimum Required

* Strong analytical, data management and PC skills.

Training Preferred/Desired

* Interqual, Milliman and Midas knowledge

Special Skills Minimum Required

* Strong clinical assessment skills and knowledge of medical standards of care.

* Extensive experience in dealing with medical staff and medical staff communities.

* Excellent interpersonal communication and negotiation skills.

* Knowledge of third party payer systems and levels of care.

* Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.

* Knowledge of principles related to release of information and maintenance of confidentiality of data.

* Knowledge of basic infection control practice.

* Understanding of pre-acute and post-acute venues of care and post -acute community resources.

* Strong organizational and time management skills, w/ability to prioritize multiple tasks and role components.

* Ability to collaborate with physicians, nurses and other hospital staff.

Licensure and/or Certifications Required

* RN

Wentworth-Douglass Hospital is an Equal Opportunity 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.