Case Manager, Per Diem

Exemption Status:

Schedule Details:

Scheduled Hours:

Shift:

Hours:

Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Major Responsibilities:
1. Maintains responsibility for the coordination and submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties
2. Is the key contact person for all Medicare RAC denials and processes each denial following the established framework.
3. Meets with the Case Managers to review the medical record to gather missing supportive documentation to strengthen the appeals process.
4. Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
5. Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third-party payer.
6. Interfaces with physicians, Patient Financial Services, Patient Access and Medical Records to obtain necessary information as needed to respond to denials.
7. Enters all denial activity into denial tracking software on a daily basis as third party payer responses are received.
8. Utilizes Physician Advisor to interface with physicians as needed.

9. Jointly maintains with Finance:
a. Tracking of denials;
b. The level in the appeals process for each denial;
c. The financial impact of denial management outcomes;
d. And successfully overturned decisions.

10. Generates reports of denial activity on a quarterly basis with analysis of data and significant trends to the Manager for Case Management and Revenue Cycle Team.
11. Assists in the orientation of new staff regarding the denial and appeals process.
12. Maintains up to date information from payers and distributes changes to all staff and departments involved in the appeal/denial process.
13. Regularly reviews observation and inpatient status determinations and serves as a resource to case managers, coding, and financial services regarding this status.
14. Provides ongoing education regarding insurance requirements and appropriate documentation for case managers and physicians. This includes periodic concurrent review of documentation with case managers and physicians.
15. Monitors and provides feedback to case managers, clinical staff, and physicians regarding appropriate documentation for patient conditions.
16. Oversees relevant auditing and monitoring related to utilization review and case management activities, such as the PEPPER report, Medicare notices and appeal rights.
17. Coordinates the monthly Utilization Review Committee in collaboration with t the physician chair.

18. Under the direction of the CNO/COO, ensures operational excellence within the department to provide support to others and quality service in accordance with applicable policies, procedures and professional standards.
a. Oversees daily departmental operations to ensure that quality services are provided in an efficient and effective manner, meeting or exceeding all applicable regulatory licensure and accrediting regulations.
b. Develops, maintains and consistently analyzes performance improvement outcomes to improve departmental services consistent with Hospital and regulatory requirements.
c. Develops and maintains departmental productivity measurements and adjusts resources to meet Hospital, departmental standards and budget obligations.
d. Monitors and coordinates improvement activities related the HCAHPS and Press Ganey.

19. Seeking appropriate counsel from Human Resources and/or Director/Senior Manager, responsible for effective human resource management to achieve consistent and fair treatment of all staff, high productivity and positive employee relations
a. Develops and supports staff to encourage high employee morale and to minimize negative turnover, overtime and absenteeism.
b. Utilizes participative management practices in creative problem-solving.
c. Offers creative solutions or alternatives to departmental staffing and/or individual employee discipline concerns.
d. Consistently and fairly interprets and enforces Human Resources policies, including appropriately addressing employee counseling and discipline issues.
e. Consistently, and in a timely way, reviews performance of staff consistent with the Hospital's performance evaluation program.

20. Assists in achieving effective fiscal management of the assigned departments' operations to ensure proper utilization of financial and other resources.
a. Consistently maintains high quality and timely department services while meeting or exceeding all budgetary goals and objectives.
b. Investigates and suggests creative alternatives to the established budgets to respond to shifting demands or resources.
c. Contributes to preparation of budgets that are complete and accurate allowing ample opportunity to review, comment and adjust in a timely manner.
d. Consistently recommends cost savings and revenue generation through innovative methods.

21. Demonstrates professional leadership and involvement within the Hospital, the System and in the community served to promote support of the Hospital.
a. As appropriate, actively participates in a variety of Hospital committees and task forces and any appropriate community activities.
b. Participates in education programs to remain knowledgeable of current trends and standards.
c. Participates in and provides support and consultation for the planning and implementation of Hospital or System programs and projects. Works proactively and effectively to ensure interdepartmental success at resolving process issues.
d. Responsible for the effective and timely completion of special projects as assigned.
e. Responsible for all patient complaints related to care and follows up on all Press Ganey comments. Patient Experience includes service recovery.
f. Provides coaching and training for managers and staff in relation to patient experience.

22. Performs and/or oversees integrated and concurrent utilization, quality and discharge planning reviews of all admissions
a. Accurately certifies admissions and continued stays using Interqual criteria.
b. Conducts timely reviews of all cases and maintains accurate files.
c. Appropriately reviews cases for communicable diseases and hospital acquired infections using the CDC standards
d. Appropriately refers cases (i.e., denials and quality issues) to physician
e. Collects and reports data elements and clinical reviews for certification by insurers.

23. Conducts and/or oversees that there are ongoing assessments of each patient's level of care and that there is collaboration with physicians to facilitate appropriate discharge and or transfer
a. Using defined standards and policies, assesses the patient and family for discharge needs and develops discharge plans based on defined needs.
b. Appropriately refers to and uses hospital and community resources and services.
c. When necessary, uses the appeal process to advocate for the patient
d. Provides family and patient education related to discharge options and resources.

24. Responsible for proper performance of Case Management process, consistent with professional standards, department policy and procedures.
a. Coordinates the scheduling of personnel, in-house education to Case Management and other departments to maintain current knowledge of community resources.
b. Coordinates all correspondence related to reviews by outside approval agencies and collaborates with the patient billing function to identify and resolve patient billing issues.
c. Reviews and presents quality indicators to appropriate physicians and committees.
d. Works collaboratively with hospital personnel/departments regarding identified quality of care issues to develop process/strategies to improve performance.
e. Serves on Hospital committees as assigned by CNO/COO and serves as secretary for Utilization Review Committee.
f. Conducts an annual appraisal of the competency and performance of staff in the Case Management department.
g. Assists staff in assessing educational needs.
h. Performs other duties as assigned by CNO/COO.

Standard Management Level Responsibilities:
1. Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
2. Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.
3. Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.
4. Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with system-wide initiatives.
5. Encourages and supports diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients and visitors.
6. Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.
7. Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
8. Ensures compliance with regulatory agencies such as Joint Commission, DPH, etc. Develops and maintains procedures necessary to meet regulatory requirements.
9. Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.
10. Ensures adequate equipment and supplies for department.
11. Develops and maintains established departmental policies, procedures, and objectives.
12. Ensures compliance to all health and safety regulations and requirements.
13. Maintains, regular, reliable, and predictable attendance.
14. Performs similar or related duties as required or directed.
All responsibilities are essential job functions.

II. Position Qualifications:

Licensure/Certification/Education:
Required:
1. Current Massachusetts licensure of RN
2. Graduate of an accredited school of nursing.
3. BS required

Experience/Skills:
Required:
1. Minimum 7 -10 years relevant experience including UR/ Case management in the acute care setting.
2. Expert working knowledge of all applicable level of care criteria applications-both written and electronic
3. Expert in InterQual criteria-maintains level of expertise to be hospital wide trainer
4. Comprehensive proficiency the case management role, including direct patient interaction and care planning
5. Expert knowledge of current reimbursement models: Commercial, managed care, Medicare, Public Assistance.
6. Excellent interpersonal communication and negotiation skills with physicians, payers and peers.
7. Ability to engage and educate colleagues regarding utilization, regulatory and compliance issues.
8. Ability to work independently with excellent organizational skills and make decisions objectively.
9. Strong analytic, data management and computer skills.
10. Technical writing ability for appeal letters and reports.
11. Analytical abilities to aggregate and report findings and to assist in obtaining solutions to problems.
12. Must be able to work independently and prioritize work.
13. Must be able to manage multiple priorities.

Preferred:
1. Certification in Case Management, Billing/Coding preferred

III. Physical Demands and Environmental Conditions:

Constantly:
- Reaching, grasping, working indoors
- Precise hearing, vision
- Lifting, carrying, pushing, pulling 0-10 pounds

Frequently:
- Standing, walking, bending, repetitive movements, high stress level
- Precise motor skills

Occasionally:
- Sitting, pushing, pulling, twisting, climbing
- Lifting, carrying, pushing, pulling 10-50 pounds

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.