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Baystate Health Hospital RN Case Manager Wing 40 1st in Palmer, Massachusetts

Summary:

Responsible for the coordination and direction of all utilization/case management activities to support and implement the goals of the utilization management program and plan. Maintains oversight responsibility for the review of medical necessity and appropriateness of care against screening criteria and for infection control, quality and risk assessment. Coordinates the discharge planning function in conjunction with the discharge planner/social worker, assist with investigation and problem solving as needed. Assists the medical director with all utilization activities as requested and directed. Responsible for coordination and presentation of utilization management program. Directs performance improvement activities within the department.

Job Responsibilities:

1) Works with denial management to provide applicable information to the team to assist in the appeals process.

2) Communicates appropriately and clearly to department director, physicians, staff, CNO, administrative team and billing department.

3) Reviews utilization management activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained.

4) Consults other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution.

5) Collects and prepares the documentation for the resolution of appeals and grievances.

6) Utilizes Interqual criteria including Cerme.

7) Assists Patient Accounts in solving issues regarding patient billing.

8) Works at maintaining good rapport and a cooperative working relationship with peers.

9) Adheres to dress code, appearance is neat and clean.

10) Reports to work on time and as scheduled, completes work within designated time.

11) Wears identification while on duty, uses computerized punch time system correctly.

12) Represents the organization in a positive and professional manner.

13) Complies with all organizational policies regarding ethical business practices.

14) Communicates the mission, ethics and goals of the hospital.

15) Completes annual education requirements

16) Maintains regulatory requirements

17) Maintains patient confidentiality at all times regarding HIPAA regulations.

18) Attends/participates in the Utilization Management Committee meetings.

19) Resolves personnel concerns at the departmental level, utilizing the grievance process as required.

20) Ensures compliance with policies and procedures regarding operations, fire, safety and infection control. Actively participates in performance improvement activities.

Required Work Experience:

1) 1 or more years utilization management experience in the managed care environment preferred

2) 1 or more years acute hospital, home health, hospice, inpatient men(4/10tal facility experience required

Skills and Competencies:

1) Ability to effectively communicate in English, both verbally and in writing

MA RN License

CPR BLS

Hours/Shift:

40-hour standard full-time position with a every 5th weekend commitment

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Bachelor of Science (Required)

Certifications:

Registered Nurse - State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

Ab out Baystate Health

Baystate Health (BH) is one of New England’s leading and largest integrated health care organizations, serving a population of nearly one million people throughout western New England. With roots dating back to the founding of Springfield City Hospital in 1873, Baystate Health has been providing high-quality and compassionate health care in western Massachusetts for more than 145 years. With more than 12,000 employees, a medical staff of nearly 3,100 physicians, and a net patient service revenue of more than $1.4 billion, the ever-growing health system includes five Massachusetts hospitals and the Baystate Mary Lane Outpatient Center in Ware:

  • Baystate Medical Center in Springfield

  • Baystate Children’s Hospital (located at Baystate Medical Center)

  • Baystate Franklin Medical Center in Greenfield

  • Baystate Wing Hospital in Palmer

  • Baystate Noble Hospital in Westfield

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