Job DescriptionThe Department of Orthopaedic Surgery & Rehabilitation Medicine at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Rehabilitation Case Manager. The successful candidate will:
- Report to the Rehabilitation Medicine Division Administrator.
- Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs).
- Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate.
- Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians.
- Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes.
- Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge.
- Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation.
- Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted.
- Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan.
- Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds.
- Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module.
- Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization.
- Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate.
- Be a team player and a role model for other staff members and students.
- Model the organization's WE CARE values.
- Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description.
QualificationsRequired Qualifications- Bachelor of Science Degree in Nursing (BSN) or Medical Doctor Degree (MD).
- New York State Registered Nurse Licensure or Medical Doctor Licensure.
- Current Patient Review Instrument (PRI) Certification.
- 2+ years of experience in case management.
- Computer proficiency in Microsoft Word, Excel, PowerPoint.
- Strong interpersonal, communication, administrative, and organizational skills.
- Or, a satisfactory equivalent combination of experience, education and training to the above.
Preferred Qualifications- Graduate Degree in a healthcare related discipline.
- Case Management Certification.
- Experience with Orthopaedic Surgery service line.
- Competency/experience with Careport, Allscripts EHR.
