New 
perdiem case manger
 Lifespan | |
 United States, Rhode Island, Newport | |
| 20 Powel Avenue (Show on map) | |
 Dec 23, 2025 | |
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SUMMARY:
Reports to the Director of Care Management or designee. As a member of a multidisciplinary team, collaborates with physicians, nurses and medical directors to coordinate, facilitate and expedite patient care services across the continuum from pre-admission to discharge and continuing care. As a member of that team, shares responsibility for the implementation of the discharge plan; ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources. All functions are carried out in consideration of the aging processes, human development stages, cultural patterns and patient choice in each step of the care process. In collaboration with the physician of record and the Utilization Review Committee physician, ensures the appropriate level of patient care is provided and that admission and concurrent authorizations from third party payers are obtained. Ensures appropriate and timely utilization of resources and services so that patients receive high quality, safe and fiscally responsible care. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate RESPONSIBILITIES: Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area. Remains current on the latest concepts, techniques, and methods relative to his/her service. Demonstrates knowledge of federal and state rules and regulations. Applies InterQual level of care screening criteria to all admissions within one business day of admission. Interacts with team and physicians to resolve any level of care discrepancies and ensures accurate documentation. Discusses with attending of record when patient level of care criteria is not met to discuss a plan of action. Provides clinical information to third party payers for certification or authorization of inpatient services as well as any other details necessary to support the discharge plan. Coordinates the collection and transmittal of pertinent clinical information required to complete arrangements for post-discharge and/or placement. Serves as a liaison with third party payers as necessary to clarify level of care questions. Coordinates the length of stay with the physician, care team and patient. Discuss approaching discharge readiness of patients. Ensures team is informed of insurance qualifiers that may affect the discharge plan. Prior to planned discharge, ensures that the patient and family have received education on his/her hospital course, length of stay, third party requirements, and available alternative settings for care. Reviews all Medicare patient admissions daily and ensures the appropriate level of care for patients per Medicare and insurance regulatory guidelines. Conducts concurrent reviews on all patients at a minimum of every three days to facilitate patient throughput during current episode of care, and to identify delays. Supports the team in analyzing variances in length of stay to minimize delays and maximize the efficient use of resources. Facilitates and expedites care across the continuum. Communicates to the team excess day and denial information as well as other relevant third-party issues in to be more proactive in managing the episode of illness. Provides education to members of the healthcare team regarding Medicare and regulatory guidelines for appropriate levels of care, the HINN delivery and the patient appeal process. Answers patient questions regarding the Medicare Outpatient Observation Notice (MOON) according to the Centers for Medicare and Medicaid Services. Delivers Hospital Issued Notice of Non-coverage (HINN) to Medicare Beneficiaries when acute inpatient admission is not medically necessary or could be furnished in an alternative setting. Initiates and completes concurrent expedited patient appeals and advises patients of insurers' response, provides guidance and counsel on the appeal process and their care options. Reviews and acts as a change agent by identifying opportunities to improve patient flow and identifies and reduces service delays through problem resolution and follow-up. Identifies and tracks service and discharge patient delays. Promotes patient satisfaction by proactively providing clinical information to third party payers to ensure authorization for hospital services and conducting expedited appeals of denied services in collaboration with the patient's physician of record. Participates in departmental and/or interdepartmental quality improvement activities as requested: i.e. OpX teams, weekly long LOS reviews, interdisciplinary rounds, readmission reviews. Participates in ongoing education-related professional activities and affiliations to maintain an advanced level of knowledge of patient care services, third party payer and managed care requirements and case management. MINIMUM QUALIFICATIONS: Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing. BASIC KNOWLEDGE: Graduate of a School of Nursing with current license to practice as a Registered Nurse in the State of Rhode Island. Bachelor's Degree in Nursing required; Master's Degree preferred. Certification in Case Management by a nationally organization preferred or to be obtained within 1 year of hire. AHA BLS Provider required. EXPERIENCE: Five years' clinical experience with recent experience in utilization review, case management, community case management, patient navigation or discharge planning is strongly preferred. Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families. Must exhibit a collaborative approach and method of communication to interact successfully on as daily basis with a wide and diverse population of both health care providers, insurers, patients and their families. Familiarity with InterQual care management criteria is required, as well as a high level of knowledge concerning utilization review, healthcare finance and the requirements of relevant payers. Demonstrates knowledge and skills necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process. Must be proficient in the use of Microsoft Office software including email and Outlook calendar and have basic keyboarding skills. WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS: General hospital environment with occasional stressful conditions associated with patient care. Risk of exposure to blood borne pathogens and disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures. Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means. Visual acuity and finger dexterity is needed to review and carry medical records, navigate through automated system screens and type on a typical computer terminal keyboard. Lifting of up to 10 lbs. may be necessary to transport items from one care unit to the next. INDEPENDENT ACTION: Responds to individual patient-care situations demonstrating knowledge and skills acquired through education, certification and work experience. SUPERVISORY RESPONSIBILITY: None. Pay Range: $37.86-$75.71EEO Statement: Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment. Location: Newport Hospital - 11 Friendship Street Newport, Rhode Island 02840Work Type: m-f, 8:00-430, one weekend /one holidayWork Shift: DayDaily Hours: 8 hoursDriving Required: No | |