Overview RN Case Manager Per Diem at South Shore Health
Location: LOC0001 - 55 Fogg Road, Weymouth, MA 02190
Department: SSH Care Progression
Status: Part time
Shift: Day (United States of America)
Compensation Pay Range: $59.42 - $86.20
Responsibilities Under the general supervision of the Case Management Manager, act as a patient advocate/Case Manager to SSH&EC clients. Coordinate, negotiate, procure services and resources for, and manage the care of complex patients to facilitate quality and cost-efficient outcomes. Apply review criteria to determine medical necessity for admission and continued stay. Provide clinically-based case management, discharge planning and care coordination to facilitate cost-effective quality healthcare. Assist in identification of appropriate utilization of resources across the continuum of care.
Work collaboratively with interdisciplinary staff internal and external to the Organization. Participate in quality improvement and evaluation processes related to the management of patient care.
Commits to working a minimum of 32 hours, with at least 16 hours (in 2 shifts) worked during a night and/or weekend per 4 week schedule. Also works 1 major summer or winter holiday.
Identify and review observation patients to determine the correct patient level of care daily prior to 12 PM. Consult with physicians, nursing, admitting, and outside insurance case managers to determine appropriate status of patient. Refer questionable status to internal physician advisor or EHR according to the Departmental Process.
Coordinate with physicians to notify them of decisions, ensure documentation supports medical necessity, and manage insurance coverage changes as needed. Notify about non-coverage when applicable and obtain required physician concurrence for Medicare patients.
Continue to review patients using criteria to determine need for continued hospitalization per third party payor/insurance guidelines. Provide clinical data to contracted third-party payers to ensure reimbursement and avoid delays within 24 hours of request.
Participate in case finding and pre-admission evaluation screening to assure reimbursement. Identify transition planning problems and work with attending physicians to move patients through SSH&EC systems and referrals; initiate creative care delivery options as needed.
Assess patient acute level of care needs and implement/coordinate interventions to facilitate safe and timely discharge planning to appropriate sub-acute settings in collaboration with the Case Manager Specialist.
Foster effective communication with multidisciplinary teams, payers, and administrators; participate in daily rounds and audits; utilize SBAR for communication; support resource utilization and discharge planning for complex cases.
Maintain knowledge of payer requirements, community resources, and post-acute care options; ensure ongoing professional development and licensure/certification requirements are met.
Qualifications Minimum Education: Registered Nurse; Bachelor’s degree strongly preferred
Minimum Work Experience: 3-5 years acute care hospital experience preferred; Critical Care or Emergency Department experience highly desirable
Required Licenses/Registrations: RN
Required Certifications: ACM (Accredited Case Manager) or CCM (Certified Case Manager) within two years of hire
Required Knowledge, Abilities: Negotiation, communication, conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management, multitasking in high-stress environment; knowledge of healthcare financing, community and organizational resources, patient care processes, data analysis; utilization management related to third-party payers; post-acute care resources
Experience with Managed Care preferred
Excellent verbal and written communication skills; ability to adapt to changing priorities and regulations
Basic computer skills
Schedule: Monday through Friday 8:00–4:30; Weekend and Holiday rotation
Other Details Technology: eDischarge, EHR, InterQual, MCCM, Epic, Workday
Education/License/Certification requirements: ACM or CCM within required timeframe; RN license; Massachusetts Board of Registration in Nursing
Seniority level: Entry level
Employment type: Part-time
Job function: Health Care Provider
Industries: Hospitals and Health Care
Note: This description reflects the responsibilities and qualifications for the RN Case Manager Per Diem role as posted. All other content has been removed to improve clarity and compliance.