I. Major Responsibilities:
1. Performs assessment of patient’s physical, functional, and psycho-social needs through the use of screening tools, direct patient and family communication, medical record review, and discussions with other care givers providing services to the patient. Identifies complex patients in need of intensive case management based on established clinical and financial criteria.
2. Performs admission and concurrent reviews as assigned.  Performs inpatient reviews in accordance with payer requirements utilizing clinical criteria sets.  Meets with 3rd party case managers to discuss cases and assures timely communication of relevant clinical information to third party payers as required.  Educates practitioners on the level of care and documentation requirements.
3. Collaboratively facilitates the care of patients throughout the continuum of care. Works as a team member to support /collaborate with Care Coordination Team for monitoring level of care, and for identification of trends in clinical practices and opportunities for improvement.
4. Works with patients and families to establish objectives, goals and an action plan to meet the patient’s individual needs within the indicated level of care.  Collaborates with the physicians, other care providers and community resources in the care planning process.
5. Contacts third party payer to clarify benefit eligibility, coverage, and available resources for patients.  May negotiate conversion of benefits for previously non-covered services.  Researches alternate sources of funding for non-reimbursed services that are part of the patient’s treatment plan.
6. Coordinates, implements, monitors and evaluates outcomes of the discharge plan. Evaluates progress of this plan with the discharge planner, patient, family and the patient’s health care insurer.  Goals, interventions and time frames are revised as needed as a means of assisting the patient to achieve his/her optimal level of health and functionality.
7. Continually evaluates the patient’s level of care.  Educates the patient, family and care team regarding resource options, facilitates decision making, initiates plan, and secures resources for the patient on an ongoing basis in complex cases.
8. Participates in quality improvement on a system level through identification of opportunities for improvement, collection and analysis of data, and participation in the development and application of revised processes.  Supports departmental and medical center-wide performance improvement programs such as implementation and monitoring of clinical practice guidelines.
9. Fosters compliance with regulatory requirements, good practice, and patient care.

Standard Staffing Level Responsibilities:
1. Complies with established departmental policies, procedures and objectives.
2. Attends variety of meetings, conferences, seminars as required or directed.
3. Demonstrates use of Quality Improvement in daily operations.
4. Complies with all health and safety regulations and requirements.
5. Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.
6. Maintains, regular, reliable, and predictable attendance.
7. Performs other similar and related duties as required or directed.
All responsibilities are essential job functions.

II. Position Qualifications:

License/Certification/Education:
Required:
1. Massachusetts licensure as a registered nurse. 

Experience/Skills:
Required:
1. Three (3) years clinical experience in discharge planning or case management.  The (3) years of Case Management experience is waived if the RN has successfully completed the Framingham State College Graduate Certificate Nurse Case Management program.
2. The ability to effectively use specialized computer-based systems for the gathering, reporting, and analysis of clinical data. 
3. Excellent organizational and communications skills required.

Preferred:
1. Utilization management and third-party payer knowledge preferred.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments.  The competencies will be maintained and attached to the departmental job description.  Responsible managers will review competencies with position incumbents.

III. Physical Demands and Environmental Conditions:

Work is considered sedentary.  Position requires work indoors in a normal office environment.