Registered Nurse, Care Manager

About Us

Care New England Health System (CNE) and its member institutions—Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in important discussions about health and end-of-life wishes. CNE is helping to transform the future of health care, providing a leading voice in efforts to ensure the health of the individuals and communities we serve.

Responsibilities

• Perform utilization management, case management, and discharge planning for acute care, extended care, ambulatory, and emergency department patients.
• Assess and reassess patients’ medical necessity to ensure accurate status (inpatient, observation, or ambulatory care) using evidence-based criteria (e.g., InterQual).
• Respond to insurer requests for information and collaborate with onsite review nurses regarding insurance authorization.
• Conduct medical record reviews for level of care (LOC) and disposition planning; reassess LOC timely and discuss with attending physicians.
• Communicate with patients and families regarding medical necessity, goal length of stay, and projected discharge dates.
• Identify and intervene in system or provider-related delays (e.g., avoidable days) and escalate for secondary review as needed.
• Proactively identify patients’ readiness for transition (e.g., downgrade or discharge to post-acute care) and screen surgical procedures for medical necessity.
• Ensure compliance with Federal and State regulations (e.g., Two-Midnight Rule, certification) and manage denials/third-party payer reimbursement.
• Execute or delegate patient notices (e.g., HINN, Condition Code 44, Important Message from Medicare).
• Conduct real-time follow-up on concurrent payer denials, facilitate peer-to-peer discussions, and collaborate with appeals representatives.
• Perform timely patient and family assessments to predict readmission risk, discharge needs, and health literacy.
• Coordinate patient transitions through the hospital to manage length of stay, cost of care, and optimize hospital days.
• Assess patient teaching needs for safe transitions and complete interventions prior to discharge.
• Initiate referrals to social services and post-acute care providers (e.g., home health, skilled nursing, rehabilitation).
• Facilitate daily collaborative care rounds, ensuring the team knows patients’ goal length of stay, discharge plans, and readmission risks.
• Develop and document treatment plans, ensuring patient understanding and modifying plans as needed.
• Arrange follow-up appointments with primary care or specialist providers and address potential transition barriers.
• Coordinate patient care conferences for high-risk patients (e.g., readmissions, extended stays).
• Identify opportunities for quality improvement and participate in performance improvement activities.
• Engage in peer review, audits, and interrater reliability evaluations (e.g., competency assessments).
• Develop professional development goals and participate in internal/external committees (e.g., UR Committee, Patient Throughput Team).
• Complete follow-up calls per program requirements (e.g., post-emergency department or discharge).
• Maintain patient confidentiality and demonstrate professionalism in all communications.

Requirements

• Graduate of an accredited school of nursing with an active, unrestricted Rhode Island RN license.
• Bachelor’s degree in nursing strongly preferred; master’s in a health-related field preferred.
• Minimum of 2 years of recent acute care experience.
• Knowledge of case management, utilization review, quality assurance, and third-party payer regulations.
• High-level interpersonal, analytical, and leadership skills; effective in a team environment.
• Certification in case management (e.g., CCM or ACM) required within 24 months of employment (pro-rated for part-time staff).
• Self-motivation and commitment to continuing education and professional development.
• Membership in a professional organization (e.g., CMSA, ACMA) desirable.
• Knowledge of community resources highly desirable.