Care Manager/Readmission Prevention - Per Diem (REMOTE)

Stony Brook University•Southampton, NY

3d•Remote

About The Position

At Stony Brook Southampton Hospital, the Care Manager Readmission Prevention position requires both hospital and transitional care experience. The CMRP is directed at assessing and identifying adult hospitalized patients who may be at high risk for readmission. This RN must have good clinical and communication skills to address the needs of the patient and caregiver throughout their hospital stay, with continued follow-up at home or when transitioned from rehab.

Requirements

Bachelor's degree in nursing with 1-3 years CM experience.
NY RN license.
Acute hospital experience.
Transitional experience.
Demonstrate knowledge of discharge planning and length of stay.
Courteous, professional, focused and good listening skills.
Computer literate.
Good Customer Service/Interpersonal skills.

Nice To Haves

Master's Degree Preferred.
Bilingual Preferred.
Preferred Certified in Case Management, UM, Quality, Risk or MCG.
Preferred experience with post-acute care coordination, including acute rehab/skilled nursing.
Preferred Home Care experience.
Preferred Telehealth experience.
Preferred Discharge Planning Skills.

Responsibilities

Assesses High-Risk patients for Readmission.
Follows all readmitted patients in the ED or on the units.
Understands levels of care including Inpatient, Observation, Emergency Room, and Outpatient.
Understand the importance of readmission prevention and LOS reduction.
Knowledge of high-risk readmission criteria and diagnosis (HF, stroke, COPD).
Understand insurance coverage and authorization.
Effectively works with the interdisciplinary team regarding the transition of care including Case Managers, Social Workers, Pharmacists, Medical Staff, Nursing, Physical Therapists, etc.
Active participation in interdisciplinary rounds.
Provides follow-up phone calls and troubleshoots issues including appointments, medication authorization, medical contracts, etc.
Coordinates communication with home care agencies and post-acute facilities as needed.
Coordinates communication between healthcare professionals involved in patient care and patients.
Gathers and documents data of encounters with the patient and/or patient's family.
Fosters the utilization of community resources for patients.
Advocates on the patient's behalf to help ensure they receive appropriate follow-up care.
Works to identify and social determinates of health issues, address them, document them, and look for available services/resources.
Helps patients understand their medical conditions, treatment plans, and the importance of following medical recommendations.
Coordinates care with the outpatient CIN care management team if needed.
Computer literate in Excel, Graphs, PowerPoint, Word, Access, and Power Chart.
Tracks and trends data with analysis of information.
Actively involved in performance improvement activities including program development and improvement.
Adheres to all State and Federal requirements, RN license, JACHO, CMS and DOH regulations.
Active participant in Readmission Committee.