Care and Case Managers - Baystate Health

Req#: R21824
Category(s): Nursing, Care and Case Managers
Full Time / Part Time: Full-Time
Shift: First


The care management supervisor is responsible for educating, monitoring, assessing, and directing the daily work of the case managers and utilization management nurses. The care management supervisor reports to the BHER vice president of patient care services, with a matrix report and routine meetings with the Senior Director of Care Management.

Leads the hospital care management team responsible for the coordination of clinical care, post-acute discharge disposition, and financial outcomes of a designated population of patients. Facilitates patient's care as called for in the patient's plan of care on a daily basis. Coordinates input from all health care professionals, and conducts assessment of patient and family needs and facilitates an optimal discharge plan assuring continuity of care. Identifies and contributes to modifications in nurse and physician practice patterns, utilizing case management tools (e.g. Interqual and Midas) to achieve quality of care, patient satisfaction, and appropriate use of resources, in alignment with medical management initiatives and product line goals. Evaluates appropriateness of admissions and continued stay using approved criteria for all payers. May assist, in collaboration with attending physicians, the appeal process in response to denials by insurance companies. Collaborates with the payers through ongoing written and verbal communication concerning a patient's plan of care to optimize compliance and reimbursement potential for BHER. Works with patients, families, and all healthcare team members to arrange appropriate post-acute plans and transitions of care for all patients requiring assistance.

The care management supervisor is responsible for escalated issues, high dollar or high length of stay cases, and obstacles with payers.

Job Responsibilities: 

1) The care management (CM) supervisor practices engagement principles each day to manage case manager and UR/UM work flows and assignments, and make necessary adjustments to maximize performance. Is a resource to the CM team for appropriate management as outlined in the evidence based practice guidelines. Oversees orientation, training, and scheduling for team. Makes recommendations on team member hires, evaluations, transfers, promotions, wage changes, corrective action, termination, and related actions. The CM supervisor, in collaboration with the Patient Care Services leadership team, leads a positive work environment that facilitates the delivery of excellent patient and caregiver experiences. Creates opportunities for shared decision-making and alliances across disciplines. Makes expectations for performance clear, uses reward and recognition to foster learning and professional development opportunities; holds individuals accountable to performance expectations.

2) The CM supervisor participates in case management and UR Committee meetings and reports on issues and concerns related to case management and communicates regularly with the Physician Advisor.

3) The CM supervisor works closely with the Denials and Appeals Specialists to ensure collaboration and communication between the disciplines.

4) Uses Clinical Skills and Knowledge to ensure quality, evidence based care is provided.

5) Assesses appropriateness of admission, including level of care, and continued stay. Communicates changes in level of care to health care team and facilitates the discussion of plans for delivering care at the appropriate setting. Determine need for Physician Advisor intervention with cases not meeting admission or continued stay criteria.

6) Performs utilization analysis using pre-established screening criteria and guidelines, nursing expertise and sound judgment in accordance with departmental policies. Communicates utilization analysis information as appropriate to health care team. Uses Utilization Analysis/Management principles, insures that patient's site of care delivery is appropriate. Intervenes as appropriate utilizing departmental policies and escalates excessive length of stay, placement problems, and other issues as indicated.

7) Uses case management skills, insures that patients move efficiently through healthcare system. Reviews all cases on a daily basis to identify potential need for practice guideline utilization, to determine the anticipated LOS and anticipated discharge needs. Monitors implementation of each patient's plan of care and evaluates progress toward desired outcomes, makes recommendations and revises the plan as necessary. Assures that interventions are in alignment with medical management initiatives. Collaborates with health care team daily regarding patient care course. Identifies and reacts to variances from the plan of care promotes resolution of patient, care giver and system issues.

8) Uses case management discharge coordination skills, to insure that patients move efficiently through the healthcare continuum. Reviews all cases on a daily basis to identify potential post-acute needs, providing quality and efficient care to transition patients to their next level of care.

9) Educates the physicians and others in the health care team on any issues with regards to length of stay, medical necessity, or potential denials.

10) Maintains currency with mandatory programs and education record in accordance with hospital and departmental guidelines.

Required Work Experience: 

1) 3-5 years case management experience

Preferred Work Experience: 

1) None Listed

Skills and Competencies: 

1) Requires a working knowledge of community resources and Utilization/Quality Review standards and activities conducted by third party payers

2)  Ability to organize and prioritize workload in order to meet deadlines

3)  Must possess excellent interpersonal skills in order to interact with all levels of health care providers, support staff, and third party payers where appropriate

4)  Management or supervisory experience required

5)  Demonstrates effective and professional work habits in conjunction with hospital policies

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Case Management Certification – Other, 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.

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