Care Management Representative

About the role

This nursing position is responsible for providing care coordination, comprehensive discharge planning, daily rounding with an interdisciplinary team, utilization review/management, readmission avoidance action plan strategies, care transitions coordination and strategic plans for the Collaborative Practice Groups under the guidance of the Director of Care Management.

The Care Management Representative participates in a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services for a patient’s individual health needs under the Scope of Service for the department.

• Provides linkages, referrals, coordination, and follow-up for identified patients and those who qualify for Health Homes.
• Carefully follows up with the patient’s Primary Care Physician / Patient Centered Medical Home / Health Home based on risk status.

Responsibilities

Affirms that the Care Management Representative will assess patients within their service line to identify needs according to established guidelines & Care Management policies.

• Coordinates care, monitors patient progress daily, and establishes discharge goals based on the care plan and patient outcomes with input from the interdisciplinary team.
• Completes CM assessments and LACE tool readmission risk determinations for identified patients such as those with chronic diseases (CHF, RF, COPD, MI, PN & DM as well as those previously re-admitted or identified at-risk patients).
• Participates in daily rounds with physicians and team.
• Develops discharge goals based on patient progress and anticipated LOS targets.
• Works to minimize discharge delays and achieve appropriate discharge times.
• Documents the care plan and goals in the medical record according to policy guidelines.
• Utilizes MCG- Milliman criteria to identify severity of illness & intensity of service for appropriate utilization management and 1st level criteria reviews.
• Documents required data in Allscripts and follow the Care Management Plan Policy for utilization review & management.
• Follows through with the attending physician regarding patient status and level of care.
• As needed, consult internal and external physician advisor for 2nd level reviews.
• Initiates community resource referrals as needed based on patient choice and post-hospitalization needs for discharge and transfer.
• Coordinates interdisciplinary collaboration to achieve patient safety and a safe discharge plan.
• Maintains a working knowledge of the resources available in the community and requirements of government payers and managed care organizations.
• Provides appropriate linkages, referral coordination, and follow-up for identified patients and those requiring Health Homes and other transitions.
• Advocates for the patient's and family's needs.
• Arranges patient care conferences as needed to facilitate complex discharge planning, improve communications, and achieve quality patient outcomes.
• Participates in the goals and activities of the Collaborative Practice Groups, Magnet Councils, Interdisciplinary Committees and/or Utilization Management Committee.
• Develops and implements interdisciplinary care plans as needed for service lines and improved patient outcomes.
• Takes an active role in committee membership, agenda planning, case study presentations and committee reports.
• Serves as a resource to physicians, patients/families regarding insurance coverage/reimbursement.
• Adheres to established guidelines for working with insurance case managers and utilization specialists.
• Maintains daily insurance logs for accuracy and appropriate patient status.
• Appropriately identifies patient's level of care and collaborates with physician regarding status changes to ALC (Alternate Level of Care), skilled & custodial care for Medicare patients.
• Completes HINN notices and documentation requirements for Medicare regulations as required.
• Issues “Important Medicare Message” (IM) as required 24-48 hours prior to discharges of Medicare and/or Management Medicare patients.

Requirements

Bachelor of Science in Nursing (BSN) preferred (or matriculating towards degree achievement within 5 years of start date)

Minimum of 3 years acute care hospital experience

Qualifications

Knowledgeable of New York State and Federal Entitlement Programs and regulatory requirements

Certifications / Licensures

• Current NYS RN nursing license
• PRI Certification preferred
• CCM Certification preferred

Skills

Strong communication and interpersonal skills

Ability to work independently and as part of a team

Excellent organizational and time management skills

Proficiency in Microsoft Office applications

Ability to manage multiple tasks and priorities

Benefits

Comprehensive benefits, including medical, dental, retirement plans, tuition assistance, and wellness programs.

Opportunities to grow within the Albany Med Health System

Located in beautiful Saratoga Springs, known for its vibrant community, outdoor recreation, and cultural attractions

Our Commitment

We are an equal opportunity employer and strongly encourage individuals of all backgrounds and experiences to apply.