Holidays

Mount Sinai Health System•New York, NY

4h•Onsite

About The Position

The Case Manager (CM) is responsible for all aspects of case management for an assigned group of patients. The role determines the appropriateness of the level of care, assists in developing and implementing the plan of care in a timely manner, and identifies the expected length of stay. The CM works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team. The position participates in clinical initiatives focused on reducing length of stay, improving efficiency and quality, and optimizing resource utilization. Assignments are by unit or clinical practice area and may require work on other units or services. The CM reviews new admissions and continued stays using standardized criteria; assesses clinical, psychosocial, and functional status; coordinates care progression and discharge planning; documents reviews and outcomes; communicates with patients, families, payors, and the interdisciplinary team; and supports utilization review and appeals. The role also obtains authorizations for post-discharge services, assesses clinical readiness, and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring residential health care facility placement.

Requirements

Bachelor’s degree in Nursing.
Current New York State RN nursing license.
Manager experience or a minimum of 3–5 years of RN experience in an acute care setting.
Basic Life Saver (BLS) certification issued by the American Heart Association.
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 ongoing inpatient care.
Collaborate with physicians and 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, and follow up on delays in treatment or reporting of results.
Develop patient care goals with physicians, the interdisciplinary team, and patients or families.
Coordinate activities, strategies, and interventions to move patients through the continuum of care.
Document outcomes and internal or external barriers, identify reasons for readmissions, and collaborate on strategies to reduce readmissions.
Refer appropriate cases to the physician advisor to support timely care progression and discharge planning.
Discuss the plan of care and coordination of services with patients and families based on clinical needs and available resources.
Maintain working knowledge of utilization review requirements for payors and provide requested clinical information to managed care companies in a timely manner and in accordance with contractual agreements.
Collaborate with physicians and managed care companies on concurrent denial appeals and coordinate communications between physicians and payor medical directors as needed.
For psychiatry cases, document utilization review notes in the medical record according to OMH guidelines.
Assess, communicate, and monitor the discharge planning process; obtain managed-care authorizations for post-discharge services; assess clinical readiness; and complete the PRI for patients requiring residential health care facility placement.
Liaise with the financial department regarding current insurance coverage.
Collaborate and participate in appeals with members of the interdisciplinary team.
Develop and maintain effective working relationships with the interdisciplinary team and case managers at managed care organizations.
Participate in nursing orientation and interface with other Medical Center departments.
Support the Medical Center’s mission, vision, philosophy, and goals.