Care Manager - Registered Nurse - Full Time Nights

NYU Langone Hospital—Suffolk is a 306-bed medical center providing care to residents of eastern Long Island. The hospital facility includes the Knapp Cardiac Care Center, a modern ambulatory surgical pavilion with specialized services such as women's imaging, a sleep laboratory, and bariatric surgery. It operates a Provisional Level 2 Trauma Center and a Primary Stroke Center designated by the New York State Department of Health, offering 24/7 expert neurological care. Additionally, the hospital has multiple outpatient sites, including a wound care center, a hemodialysis center, and various primary care and specialty offices.

About the role

The RN Care Manager collaborates with the interdisciplinary team to implement the plan of care and transition strategies, ensuring desirable patient outcomes, appropriate length of stay, efficient resource utilization, and increased patient and family involvement. Responsibilities include patient assessment, monitoring of the plan of care, coordination with the interdisciplinary team and third-party payers, utilization management, and facilitating continuity of care across settings.

Responsibilities

Utilization Management

• Performs admission review within 24 hours using InterQual Criteria to determine medical necessity for admission.
• Initiates contact with attending physicians to gather additional information supporting medical necessity when needed.
• Suggests alternative levels of care or treatment plans for patients not meeting medical necessity criteria.
• Refers cases for second-level review when medical necessity or level of care requirements are not met.
• Documents reviews in Soft Med and submits them to third-party payors in a timely manner.
• Follows up with payors for authorization responses and ensures days are approved and recorded.
• Advocates for patients, families, physicians, and the facility to secure benefits from payors.
• Communicates third-party payor guidelines to patients and families.
• Conducts continued stay reviews based on clinical condition and payor requirements.
• Collaborates on prevention plans to avoid payor denials and problem-solves when denials occur.
• Manages concurrent denial/appeal processes with the UR Specialist.
• Assesses the appropriateness and timeliness of care, diagnostic testing, and clinical procedures.
• Issues denial letters as required and resolves resource issues, escalating to management when needed.
• Refers complex psychosocial or medical cases to social workers per department guidelines.
• Communicates with attending physicians to clarify care plans and escalates cases not meeting continued stay criteria.

Discharge Planning

• Leads transition planning from admission to discharge, assessing patient/family needs, preferences, and resources.
• Completes discharge planning assessments within 24 hours of admission for all assigned patients.
• Collaborates with physicians and healthcare teams to identify patient needs and documents information in the EMR.
• Provides information on available resources and payor guidelines to patients and families.
• Ensures patients and families understand anticipated discharge dates and are involved in post-discharge planning.
• Refers complex psychosocial or medical cases to social workers per department guidelines.
• Completes the PRI in a timely manner as required.
• Initiates referrals to authorized facilities and agencies for post-hospital care.
• Ensures patients' right to choose providers by offering a list of agencies and facilities meeting their needs.
• Acts as a liaison between the hospital and community resources to ensure continuity of care.
• Maintains positive relationships with community agencies to maximize patient access.
• Stays updated on community resources and regulatory requirements impacting discharge planning.
• Contributes to process improvements for continuity, transitions, and patient-centered care.

Care Progression

• Identifies anticipated discharge dates at admission in collaboration with the healthcare team.
• Ensures patients and families are aware of the care plan and anticipated length of stay.
• Monitors patient progress and intervenes to facilitate timely discharge.
• Attends daily Patient Care Progression Rounds and follows up on identified issues.
• Facilitates communication among team members to resolve care plan issues.
• Encourages interventions appropriate to the patient’s admission reason.
• Initiates referrals to expedite care, treatment, and services (e.g., social work, PT, speech therapy, palliative care).
• Consults clinical experts to explore alternative treatment plans.
• Identifies and documents avoidable delays in care and collaborates to prevent them.
• Escalates unresolved issues per department guidelines.

Requirements

• Current NYS Registered Nursing License.
• Bachelor’s or Master’s degree in Nursing preferred.
• Case Management certification from an accredited body preferred.
• Minimum 5 years of clinical experience and 3-5 years of hospital inpatient Case Manager experience.
• Knowledge of Federal and State regulations related to hospital reimbursement, utilization review, and discharge planning.
• Experience with high-risk population assessment and intervention.
• Working knowledge of Clinical Documentation Improvement (CDI) training.
• Proficiency with hospital/care management software, electronic documentation, and EMR data compilation.
• Working knowledge of Microsoft Outlook, Word, Excel, PowerPoint, and scanning.
• PRI and Screen certifications preferred.

Pay

The salary range for this role is $115,318.97 - $148,068.97 annually. Actual salaries depend on experience, specialty, education, and hospital need. This range does not include bonuses, incentive pay, differentials, or other compensation.

Schedule

Full-time nights, Monday through Friday, 8:00 PM to 8:00 AM.