Care Manager - Readmission Specialist

Stony Brook University • Stony Brook, NY

12d • Onsite

About The Position

At Stony Brook Medicine, the Care Manager – Readmission Specialist identifies hospitalized patients who may be at a high risk for readmission. The RN following these patients must have good clinical and communication skills to address the needs of the patient and caregiver throughout their hospital stay. Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

Requirements

• Prior experience with Care Management or Utilization Management
• Understand levels of care including Inpatient, Observation, ED and Outpatient
• Understand the importance of readmission prevention and LOS reduction.
• Knowledge of high-risk readmission criteria.
• Understand insurance coverage and authorization.
• Effectively work with an interdisciplinary team regarding transition of care including Case Managers, Social Workers, Pharmacists, Medical staff, Nursing, Physical Therapist, etc.
• Active participation in rounds
• Gather and document all necessary encounters with the patient and/or patients’ family.
• Bachelor’s degree with 3-5 years CM experience
• NY RN License
• Acute hospital experience
• Transitional experience
• Experience with post-acute care coordination, including acute rehab/skilled nursing.
• Computer proficient in Electronic Medical Record applications
• Demonstrate knowledge of discharge planning and length of stay
• Courteous, professional, focus and good listening skills
• Weekend flexibility
• Good Customer Service

Nice To Haves

• Bilingual
• Certified in Case Management, UM, Quality, Risk or MCG
• Home Care experience
• Telehealth experience

Responsibilities

• Identify high-risk patients and intervene with the support of the medical team to improve outcomes.
• Monitors and coordinate an interdisciplinary plan of care with the patient and their support team.
• Participate in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided to the patients.
• Documents the case management plans such as clinical needs, barriers, utilization of resources via assessments and/or progress notes.
• Help connect the patient with appropriate resources, facilities, and providers.
• Communicate with multidisciplinary patient care team and patients/families.
• Run reports and identify patients at a high risk for readmission.
• Advocating on the patient’s behalf to help ensure they receive appropriate care.
• Works to identify any social determinates of health issues, address them, document them, and look for available services.
• Help patients understand their medical conditions, treatment plans, and the importance of following medical recommendations.
• Follow patients telephonically post-discharge and assist with barriers to care.
• Track and trend data with analysis of information.
• Actively involved in performance improvement activities including program development and improvement, data collection and analysis.
• Adheres to all State and Federal requirements, RN license, JACHO, CMS and DOH regulations.
• Maintain high level customer service.
• All other duties assigned as needed

Benefits

• Generous leave
• Health plans
• State pension

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level