Care Manager

Saint Barnabas Medical Center•New York, NY

77d•Onsite

About The Position

The Care Manager promotes a safe, cooperative, and professional healthcare environment to ensure optimum patient care. This role adheres to all hospital policies and procedures, prioritizing customer service by treating patients, visitors, and co-workers professionally and courteously. The Care Manager effectively communicates about hospital services and ensures concerns reach the appropriate personnel in a timely manner. They demonstrate standards of performance and behaviors consistent with the DRIVE to Patient-Centered Excellence. Key responsibilities include managing concurrent denials by evaluating payer denials for medical necessity, notifying the healthcare team, initiating concurrent appeal processes, and documenting outcomes. The role also involves assisting with potential medical and social delays in discharge, contacting managed care companies to justify admissions and continued stays, and performing retrospective reviews. Additionally, the Care Manager reviews concurrent denials using Interqual criteria, coordinates appeal processes, and secures medical records as needed. They also review elective ambulatory surgery cases for appropriateness of inpatient setting and assist in preparing administrative reports. The position requires maintaining proficiency in various hospital and departmental applications and documenting all communication and follow-up activities.

Requirements

Graduate from a recognized Nursing School or College.
Evidence of continuing education courses, conferences or seminars.
Current New York State RN License
PRI certification within one year of hire.
3-5 years clinical nursing experience, preferably in an acute care hospital.
Minimum of 2 years case management experience required.

Nice To Haves

Bachelor’s Degree preferred.
Denials and Appeals experience preferred.
Managed Care experience is also preferred.

Responsibilities

Promotes a safe, cooperative and professional health care environment to ensure optimum patient care.
Adheres to all hospital policies, procedures, rules and regulations.
Makes Customer Service a priority, treating customers (patients, visitors, and co-workers) in a professional manner exercising courtesy and tact.
Demonstrates the standards of performance and behaviors consistent with the DRIVE to Patient-Centered Excellence.
Evaluates denials received concurrently from payer for medical necessity.
Notifies all members of the healthcare team of the denial, and initiates concurrent appeal process.
Documents outcomes in the ACM.
Assists with all possible medical and/or social delays in discharge.
Contacts managed care companies to communicate the clinical justification of the admission and/or continued stay.
Performs retrospective reviews as requested, including but not limited to short stays, Friday/weekend admissions and discharges.
Reviews concurrent denials, utilizing Interqual (CERMe) criteria, to ensure medical necessity.
Coordinates and sets up concurrent / expedited appeal process as requested.
Secures copies of the medical record as needed.
Reviews elective ambulatory surgery cases using the Interqual Inpatient Criteria to determine appropriateness of inpatient setting, and make recommendation as appropriate.
Prints and sends medical records of Addiction Medicine short stays that have not been reviewed, as requested by the behavioral review agencies.
Follows up appeal status and outcome of concurrent denials and peer to peer activities, and documents in appropriate software program.
Provides assistance to the social worker and case manager in obtaining authorizations from the managed care organization (that are delayed over 24 hours), for new placements, as directed.
Assists the Director of Case Management in the preparation of administrative reports.
Assists in the completion of PRIs as requested, with maintenance of training and certification.
Performs retrospective appeals for At-Risk SBH Health First denials as required.
Documents concurrent denials and appeals per department policy and maintains database to track denials and outcomes.
Maintains organized files of regulatory communications, denials, appeals, correspondence, medical records and supplemental documentation.
Maintains proficiency in the use of hospital and departmental applications: HBO, EMR, Interqual, CERMe, and ACM.
Documents follow up telephone calls and other communication per departmental policy.
Organizes information making it readily available to others as appropriate.
Identifies problems early and effectively resolves them.
Uses data effectively for planning and decision making.
Methodically works toward departmental goals.
Performs other departmental tasks as requested and directed.