Job Description

Position Summary:
We have an exciting opportunity to join our team as a Care Manager RN - Full Time, Days - 08:00 AM - 04:00 PM.

The RN Care Manager collaborates with the interdisciplinary team to implement the plan of care and transition strategies ensuring the achievement of desirable patient outcomes, appropriate length of stay, efficient utilization of resources, increased patient and family involvement, and patient/staff/family education. Implementation is accomplished through patient assessment, monitoring of the plan of care, review activities, coordination with the interdisciplinary team and any outside third-party payers, communicating with physicians, performing utilization management activities to avoid denials, reduce avoidable delays and control costs where possible, and by facilitating continuity of care across settings.

Job Responsibilities:

Utilization Management

• Demonstrates accountability for utilization management functions and communication with payers to assure authorization and payment for hospital stay.
• Performs admission review within 24 hours of admission on all patients in case load utilizing InterQual Criteria to determine if patient meets medical necessity for admission.
• Initiates contact with attending physician to solicit additional information to support medical necessity for admission when there is not adequate information in the medical record.
• Suggests alternative level of care/treatment plan for patients not meeting medical necessity for admission.
• Refers cases for second level review that do not meet medical necessity or level of care requirements, according to department procedure.
• Documents review in Soft Med according to department procedure.
• Submits reviews to third party payors according to contract requirements in a timely manner.
• Assures days are approved and information is entered in Soft Med in a timely manner.
• Follows up with third party payors when there is a lack of response to request for authorization.
• Advocates for the patient, family, physician, and facility to obtain benefits from third party payors and others that provide financial assistance.
• Communicates with patients and families to ensure understanding of third-party payor guidelines.
• Conducts continued stay review as indicated based on clinical condition and third party payor requirements.
• Collaboratively institutes prevention plans to avoid third party payor denials and problems solves with the health care team when denials are received.
• Manages concurrent denial/appeal process in collaboration with the UR Specialist.
• On a concurrent basis, assesses the appropriateness and timeliness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues, and documentation completeness.
• Issues denial letters as indicated according to department procedure.
• Acts collaboratively to resolve resource issues, keeping manager/director informed as needed.
• Refers cases with complex psychosocial and medical issues to the social worker according to department guidelines.
• Communicates with the attending physician to clarify information regarding the plan of care as needed.
• Escalates cases not meeting continued stay criteria or when an alternative level of care is more appropriate when barriers to care progression are unresolved, according to department procedure.

Discharge Planning

• Leads and implements the transition planning process from the time of admission to discharge by effectively assessing patient/family needs, preferences, and available resources.

• Completes a discharge planning assessment for all patients in assigned case load within 24 hours of admission.
• Confers with attending physician and other members of the health care team to identify needs.
• Documents all pertinent information in the electronic medical record.
• Serves as a resource and advocate for patients/families by providing information regarding available resources appropriate for the patient's discharge plan and third party payer guidelines.
• Communicates with patient/family to ensure understanding of anticipated discharge date and involvement in planning for care after discharge in a consistent and timely manner.
• Refers cases with complex psychosocial and or medical issues that may create barriers to discharge to the social worker according to department guidelines.
• Completes the PRI in a timely manner as indicated.
• Initiates referral to facilities and agencies that can meet the post hospital care needs of the patient and are authorized by third party payors.
• Ensures patients' right to choice in providers of post hospital care by providing a list of agencies and facilities that can meet the patient's care needs.
• Ensures continuity of care by acting as a liaison between the hospital and community resources.
• Provides all required information to the agency/facility to facilitate a smooth transition.
• Maintains positive working relationships with community agencies and facility staff to maximize access for patients/families.
• Keeps up to date on available community resources and regulatory requirements that impact discharge planning.
• Provides input to the development of processes that improve continuity, transitions, and patient centered care across the continuum of care.

Care Progression

• Identifies anticipated discharge date at the time of admission in collaboration with the members of the health care team.
• Ensures that the patient/family is aware of the plan of care and anticipated length of stay.
• Monitors patient's plan of care and progress in relation to anticipated length of stay and intervenes to facilitate a timely discharge.
• Attends daily Patient Care Progression Rounds and follows up on any issues/barriers identified with the appropriate staff/departments.
• Facilitates communication among team members to resolve issues that may impact the plan of care.
• Encourages interventions appropriate to the reason for the patient's admission.
• Initiates referrals to the appropriate areas to expedite care, treatment, and services ( SW,PT, speech therapy, financial counselor, palliative care, etc.)
• Seeks input from clinical experts to explore acceptable alternatives to treatment plan.
• Identifies and documents avoidable delays in care and works collaboratively the healthcare team to prevent them.
• Escalates cases with unresolved issues according to department guidelines.

Minimum Qualifications:
To qualify you must have a Current NYS Registered Nursing License. B.S or M.S. preferred
Case Management certification from accepting accrediting body, preferred
Minimum 5 years of clinical medical-surgical experience and 3-5 years experience as a hospital in-patient Case manager
Must possess knowledge of Federal and State regulations pertaining to hospital reimbursement, the utilization review process and the discharge planning function
Knowledge of identification, assessment, and intervention pertaining to high-risk populations
Working knowledge of/completion of CDI-Clinical Documentation Implementation Training
Working knowledge/experience with hospital/care management software, documenting electronically, and compiling data from the electronic medical record
Working knowledge of Microsoft outlook, Microsoft Word, Excel, Power Point, and scanning
PRI and Screen certifications, preferred..

Required Licenses: Registered Nurse License-NYS

NYU Langone Hospital-Suffolk provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements. The salary range for the role is $110,353.08 - $143,103.08 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

View the Pay Transparency Notice for further details.