Job Description

The focus of this role is to collaborate on discharge planning oversight, starting from the pre-op phase, to set expectation based on interaction with providers, patients, and case management in planning for acute stay and post-acute management to meet the patient needs.
 

The impact of these interventions will enhance the acute care stay experiences, influence patient expectation and appropriate skilled nursing facility LOS, assure continuity of care to Steward's integrated (contracted) SNF and homecare partners, and improve patient outcomes through the post-acute period to decrease readmissions.

KEY RESPONSIBILITIES:
• Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources ensuring appropriate utilization across the continuum of care.  
• Has a full understanding of the payor's benefits and regulations and works within those reimbursement systems.
• Collaborates with network's physicians to provide quality focused cost-effective interventions to all clients across the continuum of care.  
• Establishes relationships with clients and their families as needed to assure the provision of services needed.  
• Coordinates these efforts with SHCN Inpatient Case Management staff. 
• Validates the execution of the discharge plan and assess the effectiveness of the plan. 
• Supports SHCN efforts to meet federal and state regulations as well as health plan specific policies and procedures. 
• Maintains documentation standards in conjunction with policy and procedures. 
•  Create a Bundled UM review meeting in conjunction with facility CM leadership
• Participates in meetings at Steward Hospitals for Readmission Prevention, Transitions of Care, Post Acute care. 
• Provides consultation and education to the client/family and other health care members as needed. 
• Understands & adheres to all health plan & regulatory guidelines including NCQA/CMS/URAC/ERISA 
• Maintains and respects patient confidentiality according to SHCN HIPAA policy and procedures. 
• Performs other functions as assigned.

REQUIRED KNOWLEDGE & SKILLS:
• current Massachusetts RN  license required
• Three years of acute medical/surgical experience highly desirable.
• Experience in case management within a home care setting, ambulatory and skilled nursing.
• Possesses a strong clinical background in acute or post-acute settings with the focus on the delivery of high quality and cost-effective care. 
• Demonstrates the ability to apply principles of critical thinking.
• Knowledge of managed care principles and physician practice.
• Display strong interpersonal skills, ability to collaborate with 
• Knowledge of case management, utilization management, and referral management.
• Collaborates with multiple providers to provide quality and cost-effective care for risk members.
• Maintains information in a confidential manner according to policy.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
I. Education:  RN license required; Bachelors degree required; Masters degree preferred.
II. Experience:  2-3 years of medical/surgical experience plus 2-3 years of SNF experience and 1-2 years of Case Management experience. 
III. Certification/Licensure:  Certification in Case Management (CCM) strongly preferred.
IV. Software/Hardware:  Strong knowledge in Microsoft Office applications – Word, Excel, Access, PowerPoint.
V. Other:  Understanding the health care delivery setting. 

Application Instructions

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