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 for the individuals and communities we serve.

Responsibilities

• Performs utilization management, case management, and discharge planning activities for acute care, extended care, ambulatory, and emergency department patients.
• Assesses patients' transition and discharge planning needs, prevents unnecessary admissions/readmissions, and facilitates timely transitions/discharges.
• Performs utilization and resource management by assessing and reassessing medical necessity to ensure accurate patient status (inpatient, observation, or ambulatory care) using evidence-based criteria (e.g., InterQual).
• Responds to insurer requests for information and collaborates with onsite review nurses regarding insurance authorization.
• Conducts medical record reviews for level of care (LOC) and disposition planning, reassessing LOC timely to ensure appropriateness.
• Discusses LOC and medical necessity with attending physicians daily and communicates with patients and families regarding medical necessity, goal length of stay, and projected discharge date.
• Identifies and intervenes in system or provider-related delays for secondary review (e.g., physician advisor, Chief Medical Officer) and tracks potential or actual avoidable days.
• Proactively identifies patients' readiness to transition (e.g., downgrade or discharge to post-acute care) and screens surgical procedures for medical necessity (e.g., SIMS plus).
• Ensures compliance with Federal and State regulations for LOC assignment and medical necessity (e.g., Two-Midnight Rule and certification).
• Manages denials and third-party payer reimbursement from preadmission through post-discharge in collaboration with Patient Financial Services (PFS).
• Executes or delegates patient notices (e.g., HINN, Condition Code 44, Important Message from Medicare, Detailed Notice of Discharge).
• Acts as a resource to PFS, including assisting uninsured patients with accessing health care insurance.
• Conducts real-time follow-up on concurrent payer denials, facilitates peer-to-peer discussions, completes Medicare short-stay reviews, and collaborates with appeals representatives.
• Performs timely patient and family assessments to predict readmission risk, discharge planning needs, and health literacy (e.g., in the Emergency Department, within 24 hours of admission, or pre-admission for planned surgeries).
• Coordinates patient flow and throughput to manage length of stay, cost of care, and optimize hospital days.
• Assesses patients' teaching needs for safe care transitions and completes interventions prior to or during hospitalization.
• Coordinates discharge/transition plans with the patient care team and proactively initiates referrals (e.g., social services).
• Facilitates and participates in daily collaborative care rounds, ensuring the team knows patients' goal length of stay (GLOS), projected discharge date, disposition plan, and readmission risk.
• Coordinates key interventions among the interdisciplinary care team to ensure timely patient care.
• Participates in hospital-based patient flow efforts and teams.
• Develops and documents specific treatment plans, discusses them with the care team, and ensures patient understanding of their role in managing their disease process.
• Identifies and recommends modifications to the plan to ensure successful discharge/transition.
• Ensures patients are discharged to an appropriate level of care agreeable to the patient/family or guardian.
• Arranges appropriate services for patients identified as at risk for readmission.
• Refers patients to primary care or specialist providers for follow-up and establishes care with a primary care provider.
• Identifies and addresses potential barriers to transition, facilitating timely care and transition planning.
• Ensures documentation is provided for post-discharge/transition care, including risk for readmission and pertinent discharge information.
• Initiates timely referrals to post-acute care providers (e.g., home health agencies, skilled nursing facilities, long-term care hospitals, acute rehabilitation facilities, assisted living facilities, homeless shelters).
• Coordinates patient care conferences for patients readmitted within thirty days of discharge or those exceeding thirty days of stay.
• Identifies and recommends opportunities for improving quality and customer service and participates in performance improvement activities.
• Participates in peer review/audit and periodic interrater reliability evaluations (e.g., competency assessments and coaching).
• Develops a plan for attaining professional development goals (e.g., set during performance review).
• Identifies patients with complex care needs and collaborates in developing, notifying, and maintaining complex care plans.
• Actively participates in problem-solving activities and internal/external committees and projects addressing quality, patient flow, length of stay, and revenue (e.g., UR Committee, Long LOS, ICD 10, Patient Financial Services, Crimson, Patient Throughput Team).
• Ensures patients' follow-up appointments with primary care or specialist providers.
• Completes or delegates follow-up phone calls per program requirements (e.g., patients released from the Emergency Department or discharged home).
• Demonstrates courtesy, integrity, and respect in communications with co-workers, patients, and the public, valuing diversity and addressing cultural or linguistic factors.
• Maintains patient confidentiality at all times.
• Performs all other related duties as assigned.

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.
• Recent knowledge of case management, utilization review, quality assurance, and third-party payer regulations.
• High level of interpersonal, analytical, and leadership skills, with effectiveness in a team environment.
• Certification in case management (e.g., CCM or ACM) or obtained within 24 months of employment (pro-rated for part-time staff). Existing staff as of November 1, 2015, must show proof of certification by November 1, 2017.
• Self-motivation and commitment to continuing education and professional development.
• Membership and active participation in a professional organization (e.g., CMSA, ACMA) desirable.
• Knowledge of community resources highly desirable.