Holidays

Mount Sinai Health Systems•New York, NY

21h•$66 - $66

About The Position

The RN/Case Manager is responsible for case management for an assigned group of patients. The role determines the appropriateness of the level of care, helps develop and implement plans of care in a timely manner, and identifies expected length of stay. The Case Manager collaborates with physicians, social workers, clinical nurses, home care services, and other interdisciplinary team members. The assignment is organized by units or clinical practice areas and may include responsibility for other units or services. The role supports clinical initiatives to reduce length of stay and improve efficiency, quality, and resource utilization. It includes assessment and coordination across the continuum of care, utilization review, discharge planning, documentation, and collaboration with patients and families, payors, and clinical teams. The position also participates in nursing orientation and interfaces with other Medical Center departments.

Requirements

Bachelor’s degree in Nursing.
Current New York State RN nursing license.
Manager experience or a minimum of 3–5 years of experience as an RN in an acute care setting.
Basic Life Saver (BLS) certification issued by the AHA.
PRI certification must be obtained within one year.

Nice To Haves

Master’s degree in Nursing.
Previous experience in home care, long-term care, or utilization review.
Experience as a Discharge Planner or Case Manager.
CCM certification; re-credentialing of CCM status is expected.

Responsibilities

Review new admissions to identify patients needing utilization review, discharge planning, or case management using standardized criteria.
Perform continued-stay reviews using standardized criteria to justify continued inpatient care.
Collaborate with physicians and other clinicians to expedite diagnostic testing, treatment, and consultations.
Document clinical reviews in the Case Management Documentation system.
Assess patients’ clinical, psychosocial, and functional status with the interdisciplinary team.
Identify and document variances affecting length of stay and discharge planning.
Follow up on delays in treatment or reporting of results.
Develop goals with the physician, interdisciplinary team, and patient and/or family.
Coordinate activities, strategies, and interventions to move patients through the continuum of care.
Document outcomes and identified internal and external barriers.
Identify reasons for readmissions and collaborate with the interdisciplinary team on strategies to reduce readmission rates.
Refer appropriate cases to the physician advisor to support timely progression of care and discharge planning.
Discuss the plan of care and coordination of services with patients and families, considering clinical needs and available resources.
Maintain working knowledge of utilization-review requirements for payors in the patient population.
Provide requested clinical information to managed care companies promptly and in accordance with contractual agreements.
Collaborate with physicians and managed care companies on concurrent denial appeals.
Communicate clinical information to payors and coordinate direct communication between physicians and payor Medical Directors when needed.
In psychiatry, document utilization-review notes in the medical record according to OMH guidelines.
Assess, communicate, and monitor the discharge-planning process; the clinical nurse initiates discharge planning on admission.
Obtain managed-care authorizations for post-discharge services.
Assess clinical readiness and complete the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement.
Liaise with the financial department regarding current insurance coverage.
Collaborate and participate in the appeals process with the interdisciplinary team.
Develop and maintain effective working relationships with the interdisciplinary team and Case Managers at managed care organizations.
Participate in nursing orientation.
Interface with other Medical Center departments.
Support the Medical Center’s mission, vision, philosophy, and goals.