South Shore Health
Per Diem Case Manager
Weymouth, MA · Part-time
Sponsorship not specifiedDetected 13 days ago
HRISEpicEHR/EMRPatient CareCommunicationCollaborationCritical Thinking
About the role
- If you are an existing employee of South Shore Health then please apply through the internal career site.
- Looks for opportunities to reduce cost while assuring the highest quality of care is maintained.
- Applies review criteria to determine medical necessity for admission and continued stay.
Requirements
- Required Licenses / Registrations
- a - Identifies potential transition planning problems in a timely manner to set up services required.
Nice to have
- Registered Nurse, Bachelors prepared strongly preferred
- 3-5 years acute care hospital experience preferred
Compensation
- Compensation Pay Range:
Benefits
- 1 - The RN Case Manager is responsible for reviewing the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
- a - Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
- c - Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity
- d - Contacts the attending physician to notify him/her of decision to issue notice of non-coverage.
- Explains UR process and insurance coverage requirements.
- Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission.
- e - Reinstates insurance coverage when patient condition becomes acute and meets criteria again.
- g - Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
- c - Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the level of care, utilizing InterQual for Observation.
- 3 - Participates in case finding and pre-admission evaluation screening to assure reimbursement.
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This listing is sourced directly from South Shore Health's careers page and normalized into a canonical job model.