Registered Nurse - Case Management

One Brooklyn Health•New York, NY

About The Position

The Case Manager assesses the medical necessity of patient admissions and continued stays using clinical documentation in the Electronic Health Record (EHR) and Milliman Care Guidelines. The role coordinates care among multidisciplinary team members, identifies factors that may contribute to readmissions, and helps arrange community, social, and financial support for safe and appropriate discharges. Case Managers support quality and pay-for-performance outcomes by identifying documentation opportunities, promoting efficient and sequential care, and advocating for timely adherence to the patient’s plan of care. They use their clinical background to support safe care transitions and may receive job training in addition to meeting the core qualifications. The position includes daily EHR reviews, communication with physicians, insurers, social workers, and other care team members, and coordination of discharge needs such as home IV infusion and wound-vac services. Case Managers document their activities and referrals in EPIC and use Careport for relevant correspondence with insurance companies and home care agencies.

Requirements

Bachelor’s degree in Nursing (BSN).
At least three years of clinical experience in one or more of the following: acute care, medical-surgical, intensive care, emergency department, or community nursing (home care).
Current New York State Registered Nurse licensure.
Basic Life Support (BLS) certification.
Patient Review Instrument (PRI) certification.
Maintain a valid New York State Registered Nurse license and BLS certification throughout employment.
Knowledge of federal, state, and JCAHO guidelines for utilization review, discharge planning, quality assurance, and infection control.
Strong written and verbal communication skills, including the ability to communicate and negotiate with other disciplines, physician practice groups, third-party reviewers, and outside entities.
Ability to work well under stress and demonstrate emotional stability and good health.
Physical mobility.

Nice To Haves

Pediatric Advanced Life Support (PALS) certification.
Case Manager Certification (CCM).
Advanced Cardiovascular Life Support (ACLS) certification.

Responsibilities

Conduct face-to-face assessments of patients’ physical, mental, and emotional barriers to self-care, community medical management, and the need for social work referrals.
Review assigned patients’ EHRs daily or as needed to assess medical necessity, including severity of illness and intensity of service, during bedside or interdisciplinary rounds.
Collaborate with social workers to identify social determinants of health that could impede patient outcomes.
Serve as a liaison between physicians and physician advisors.
Correlate medical necessity with financial and quality-of-care outcomes.
Complete clinical documentation for hospitalization reviews submitted to insurance companies, including initial, concurrent, or retroactive reviews.
Review HMO admissions for medical necessity and submit them to the HMO.
Review admissions for medical necessity within 48 hours of admission.
Communicate with attending physicians about admission guidelines.
Provide real-time interventions to prevent delays and support compliance and revenue integrity with healthcare regulations.
Inform treatment team members of EHR documentation needed under Milliman Care Guidelines for admission, transfer, length of stay, and safe discharge planning.
Identify tests, procedures, and interventions early to advance the plan of care.
Assess and collaborate with the healthcare team on the need for Alternate Level of Care designation, and document when a patient is placed on ALC.
Assess patients’ current community support and adherence to medical care, including the effectiveness of those supports for health promotion.
Collaborate with treatment team members on care plans to reduce readmissions by identifying barriers and resolutions.
Complete home IV infusion and related home care referrals for patients, and follow up with patients or families.
Complete wound-vac and related home care referrals for patients discharged home with a wound vac.
Refer patients to financial services before discharge as appropriate.
Discuss discharge planning with the treatment team and create PRIs before discharge.
Document reviews, home care referrals, PRI completion, and correspondence with insurance companies or home care agencies in EPIC and Careport.
Write brief and concise Case Management notes.
Maintain professional currency and licensure through relevant professional development activities and required training.
Adhere to Case Management Society of America standards and the Nurse Practice Act.
Apply analytical problem-solving and decision-making skills focused on quality and cost containment.
Incorporate the medical center’s customer service goals into departmental policies and systems, and review service delivery to exceed customer expectations.