Job DescriptionThe Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review Quality Assurance Senior Coordinator / RN Case Manager. The successful candidate will:
- Provide hospital case management, utilization review and discharge planning to ensure that the patient progresses through the continuum of care and discharged through a well-coordinated transition of care plan.
- Utilize standard review criteria specifically the Milliman Care Guidelines (MCG) to justify level of care, medical necessity, expected length of stay and intensity for inpatient admissions.
- Perform initial clinical reviews and continued care reviews for hospitalized patients using standardized care guidelines to determine medical necessity for inpatient admissions or for placement in other appropriate levels of care.
- Conduct an initial clinical assessment within 24 to 48 hours. Perform reassessments as necessary based on patient acuity.
- Promote interdisciplinary collaboration by providing resources to the interdisciplinary team when appropriate on issues of medical necessity and clinical documentation requirements.
- Collaborate with Departments of Social Work, Nursing and other medical teams to discuss patient treatment plan and transition of care post-hospitalization.
- Communicate with patient/family members appropriately and be cognizant of cultural facts that can affect hospital stay and discharge planning.
- Document delays or variances from expected length of stay in CarePort (Care Management Platform).
- Identify patients who were readmitted within 30-days. Assess for actual/potential risks then confer concerns to medical team and appropriate social worker. Document interaction in patients' medical record.
- Complete the Patient Review Instrument (PRI) as mandated by New York State.
- Transmit Patient Review Instrument (PRI) to facilities and MCO in order to secure authorizations for transfer to SNF and SAR.
- Facilitate concurrent request for reconsideration of potential denials. Coordinate peer interactions between SUNY University Hospital physicians and the Managed Care Organization physicians to prevent denial of reimbursements.
- Ensure patients are placed in the proper level of care by communication with the appropriate physicians
- Ensure the appropriate documents that meets regulatory requirements are in the medical record e.g. IMM forms (signed), observation notices (signed).
QualificationsRequired Qualifications- Current New York State Registered Nurse Licensure.
- Bachelor's Degree in Nursing.
- PRI Certification.
Preferred Qualifications- Graduate Degree in Healthcare preferred.
- Case Management Certification preferred.
