RN Case Manager, Hospital

Essential Functions

• Identify patients who would benefit from case management services by utilizing high-risk screening criteria.
• Perform comprehensive assessments that address the patient's medical condition, functional status, psychosocial needs, and discharge planning requirements, thereby enhancing patient care throughout the continuum.
• Employ a collaborative process of assessment, planning, implementation, care coordination, monitoring, advocacy, and evaluation to meet the individual's health care needs.
• Meets patients' needs efficiently and effectively by enhancing the patient experience, upholding institutional standards for high-quality care, optimizing resource utilization, and supporting appropriate reimbursement.
• Coordinate post-acute services, community resources, and follow-up care to facilitate safe and effective patient transitions.
• Collaborate with the interdisciplinary care team to assess medical necessity and determine appropriate levels of care.
• Conduct admission and concurrent utilization reviews using approved clinical criteria.
• Complete timely and accurate insurance reviews and secure required third-party payer authorizations as required.
• Identify and address any service delays or inappropriate utilization of healthcare resources.
• Support initiatives to reduce readmissions by enhancing care coordination, communication, and follow-up processes.
• Educate patients and families about care plans, insurance coverage, and available post‑acute care options.
• Ensure compliance with federal and state regulations related to discharge planning, including adherence to CMS regulations and organizational policies.
• Document assessments, care plans, and ongoing case management activities in accordance with organizational policy and regulatory requirements.
• Participate in quality improvement projects, audits, and special assignments as needed.

• Graduate of an accredited school of nursing (BSN preferred).
• Current Registered Nurse licensure in the Commonwealth of Massachusetts.
• CCM or ACMA certification is preferred.

• At least three years of clinical nursing experience is strongly preferred.
• A minimum of two years of experience in case management, utilization review, or discharge planning is strongly preferred.

• Demonstrates strong clinical judgment and independent decision-making abilities.
• Effectively collaborates within a multidisciplinary care team.
• Uses logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Establishes strong rapport and relationships with patients, caregivers, and team members.
• Manages time effectively, especially when working remotely from the care team.
• Proficient in Microsoft Office, Teams, 4
  
  Next, Interqual, and other industry-related software programs.

Mass General Brigham Home Care, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.