RN Case Manager In-Patient Per Diem at Martha's Vineyard Hospital (MVH)

Posted in Other 14 days ago.

Location: Falmouth, Massachusetts

Job Description:

Assists in planning, developing, and organizing the operations of the Case Management Department regarding the implementation of utilization management, coordination of care activities, quality improvement and case management activities in order to meet the requirement of The Joint Commission, state and local regulatory and/or accrediting agencies. Obtains pre-certification from third party payors as required. Performs all admission/continued stay reviews for appropriateness of acute hospital level, assessing quality of services as the patient moves through the continuum of care. Establishes and implements safe, comprehensive discharge plans to meet individual patient/family needs. Communicates with the interdisciplinary team and community resource representatives in planning for the patient's transition to post-hospital care.

As Case Management, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

Assists the Director of Quality Management in planning, developing, organizing, implementing, and evaluating the Case Management program of the Hospital.
Develops and implements departmental and interdepartmental policies and procedures relating to Case Management and the Swing Bed Program.
Coordinates the Hospital's Swing Bed Program.
Performs daily utilization review activities (assesses appropriateness of admission/continued stays.) Completes initial review within one business day of admission and updates continued stay reviews daily.
Reviews the medical/surgical treatment plan with third party payors to obtain authorization for pre
certification, admission and continued stay. (Communicates in a professional, courteous manner, respecting the third party payors need for treatment plan updates as well as patient confidentiality issues.)

Refers those cases that still do not meet Interqual criteria to the Utilization review Physician Advisor for admission or continued stay approval and contacts MASSPRO for Medicare Non-Coverage cases. Distributes Hospital-issued Notices of Non-Coverage to patient or family as indicated.
Communicates with the interdisciplinary team in planning for patients post hospital care. Attends biweekly patient care rounds and initiates appropriate referrals to social work, rehabilitation therapy and homecare liaisons as needed.
Establishes individual patients discharge plans to provide transition to outpatient or extended care providers. (Elicits the patient/representative participation in the discharge planning process while allowing for individual patient needs including: age appropriateness, language barriers, educational level and sensory deficits in discharge planning discussions.)
Coordinates/provides social and practical assistance with environmental problems including financial assistance, discharge planning and referrals to other community agencies.
Works closely with the patient/representative and family to identify the appropriate health and social service agencies for continuing care post-hospital.
Implements the final discharge plan and notifies the patient's family promptly.
Provides the required discharge documentation (patient care referrals, STAT discharge summaries) to community agencies and extended care facilities at the time of discharge in cases requiring post hospital care. Arranges air or ground transportation to other facilities.

Completes occurrence screens as part of the Hospital's patient safety program.

Educates Medical and Nursing Staffs on Interqual criteria and appropriate documentation for acute hospital care.
Pre-screens patients for respite care/swing bed admissions, collaborating with Clinical Coordinator/Nursing Supervisor on appropriateness.
Coordinates appeal process for reimbursement denials with Medical Staff, Billing, and Medical Records.
Performs other duties as deemed necessary and appropriate or as directed by the Chief Quality Officer.
Participates in community planning related to the interests of the facility and the services and needs of the patient and family.
Helps facilitate interdisciplinary team meetings on inpatients as needed.


• Registered Nurse with previous case management experience required
• Successful completion of Case Management Certification Program preferred

• Prior work in a community health, home health, or acute care or critical access hospital setting.
• Must possess a current, unencumbered license to practice in this state.

EEO Statement

Martha's Vineyard Hospital and Windemere Nursing & Rehabilitation Center are Equal Opportunity Employers. 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.

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