Holidays

Mount Sinai Health System•New York, NY

About The Position

The RN/Case Manager is responsible for case management for an assigned group of patients, including determining the appropriateness of the level of care, supporting development and timely implementation of plans of care, and identifying expected length of stay. The role collaborates with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team. It also contributes to clinical initiatives focused on reducing length of stay and improving efficiency, quality, and resource utilization. Assignments are based on units or clinical practice areas and may include responsibility for other units or services. The Case Manager reviews admissions and continued stays using standardized criteria, documents reviews, and coordinates care progression, utilization review, and discharge planning. The role assesses patients’ clinical, psychosocial, and functional status; identifies delays and barriers; develops goals with patients, families, physicians, and the interdisciplinary team; coordinates services across the continuum of care; and supports appropriate discharge planning and readmission reduction. The position provides clinical information to managed care companies, coordinates concurrent reviews and denial appeals, obtains authorizations for post-discharge services, assesses clinical readiness, and completes the Hospital and Community Patient Review Instrument (PRI) when residential health care facility placement is needed. The Case Manager also maintains collaborative relationships across the Medical Center and participates in nursing orientation.

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.
Obtain PRI certification within one year.
Basic Life Saver (BLS) certification issued by the AHA.

Nice To Haves

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

Responsibilities

Review new admissions to identify utilization review, discharge planning, and case management needs using standardized criteria.
Perform continued-stay reviews using standardized criteria to justify continued 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 goals with physicians, the interdisciplinary team, and patients or families.
Coordinate activities and interventions to move patients through the continuum of care, and document outcomes and barriers.
Identify reasons for readmissions and collaborate on strategies to reduce readmission rates.
Refer cases to the physician advisor when appropriate to support timely care progression and discharge planning.
Discuss plans of care and service coordination with patients and families based on clinical needs and available resources.
Maintain working knowledge of payor utilization review requirements and provide requested clinical information to managed care companies in a timely manner and in accordance with contractual agreements.
Work with physicians and managed care companies on concurrent denial appeals and coordinate direct physician-to-payor medical director communication when needed.
Document utilization review notes in the medical record in psychiatry 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 Hospital and Community Patient Review Instrument 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.