Performs the six essential activities of Case Management: Assessment, Planning, Implementation, Coordinate, Monitor and Reassess through the continuum of care to facilitate a safe cost-effective transition post discharge. Performs all aspects of audits and appeals including the peer to peer process.
Perform utilization review to evaluate for appropriate level of care and faxes all insurance reviews timely to prevent denials.
Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs.
Place and implement all aspects of referrals to all levels of post acute care in 4 Next.
Online documentation of interaction with patient, family and interdisciplinary team.
Interact with various third party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.
Refer cases not meeting appropriate level of care to the Physician Advisor or EHR.
Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change inpatient to observation (code 44).
Perform and monitor for quality issues and document in R.L. solutions.
Provide to the patient or family member a copy of the Important Message
Provide to the patient or representative the Observation Notification letter
Provide to the patient representative the Acknowledgement of disclosure ,obtain choices of post acute facilities or service and signature
Must be able to function independently in busy environment.
Coordinate, complete and track all clinical denials and appeals.
About Brigham and Women's Faulkner Hospital:
Brigham and Women's Faulkner 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.
Brigham and Women's Faulkner Hospital is a 171- bed non-profit, community teaching hospital located in Jamaica Plain directly across the street from the Arnold Arboretum. Founded in 1900, Brigham and Women's Faulkner Hospital offers comprehensive care in a wide variety of specialties. Brigham and Women's Faulkner Hospital is a designated Magnet hospital by the American Nurses Credentialing Center, a recognition that fewer than nine percent of all US hospitals receive.
At Brigham and Women's Faulkner Hospital, we believe that everyone should have the chance to live a healthy life. From creating breakthroughs that have paved the way for treatments around the globe to training the next generation of providers, our patients, and those we may never meet, are at the center of everything we do. If you're looking for more than a career, join Brigham and Women's Faulkner Hospital. Our patients call it better care. Our employees call it home.
Qualifications
BSN required.
Current Registration as a Licensed Nurse in the State of Massachusetts.
3 year of Utilization Review and Case Management experience required, 4 or more years preferred
5 years of Acute Care Nursing Required 6 or more preferred
CCM preferred.
EEO Statement
Brigham and Women's Faulkner Hospitalis 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.
