RN Case Review Coordinator - Faulkner

About the role

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 Acknowledgment of disclosure, obtain choices of post acute facilities or service and signature.

Responsibilities

• Accurately facilitates all documentation needed for Medicare status change inpatient to observation (code 44).
• Collaborates with patient/family and interdisciplinary team to assess for appropriate discharge needs.
• Coordinates, completes and tracks all clinical denials and appeals.
• Documents in R.L. solutions for quality issues.
• Facilitates online documentation of interactions with patient, family and interdisciplinary team.
• Interacts with various third party payers on a daily basis.
• Performs all aspects of audits and appeals including the peer to peer process.
• Performs utilization review to evaluate for appropriate level of care and faxes all insurance reviews timely to prevent denials.
• Placements and implements all aspects of referrals to all levels of post acute care in 4 Next.
• Provides to the patient or family member a copy of the Important Message.
• Provides to the patient or representative the Observation Notification letter.
• Provides to the patient representative the Acknowledgment of disclosure, obtains choices of post acute facilities or service and signature.
• Reviews for Observation status and makes changes as needed.
• Seeks out and refers cases not meeting appropriate level of care to the Physician Advisor or EHR.
• Tracks and monitors for quality issues and documents in R.L. solutions.
• Works independently in a busy environment.

Requirements

• Bachelor of Science in Nursing (BSN) required.
• Current Registration as a Licensed Nurse in the State of Massachusetts.
• 3 years 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.

Qualifications

• Bachelor of Science in Nursing (BSN) required.
• Current Registration as a Licensed Nurse in the State of Massachusetts.
• 3 years 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.

Skills

• Strong communication and interpersonal skills.
• Ability to work independently and manage multiple tasks simultaneously.
• Proficiency in utilizing electronic health records (EHR).
• Knowledge of healthcare regulations and policies.
• Excellent organizational and problem-solving skills.

Benefits

At Brigham and Women's Faulkner Hospital, we offer a comprehensive benefits package including:

• Health Insurance
• Retirement Plans
• Employee Assistance Programs
• Flexible Spending Accounts
• Life and Disability Insurance
• Generous Paid Time Off
• Professional Development Opportunities

Pay

$41.36 - $100.00/Hourly Grade RN3500

Schedule

Full-time; 40 hours