RN/Case Manager (Inpatient)-Mount Sinai Morningside Case Management-FT-Weekdays/Weekends/Holidays

Responsibilities

• Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization.
• Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay.
• Collaborates with Physician and other clinicians to expedite diagnostic testing, treatment and consultations.
• Documents all clinical reviews in Canopy.
• Supports the mission, vision, philosophy and goals of the Medical Center.
• Case Management: The CM process will include:
• Assessment of the patient’s clinical, psychosocial, and functional status in collaboration with the interdisciplinary team.
• Identification and documentation of variances affecting the LOS and the discharge planning process.
• Conducts follow-up of any delays in treatment or reporting of results.
• Planning/developing specific goals with the physician, interdisciplinary team, and the patient and/or family.
• Implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care.
• Documentation of outcomes achieved and identified internal and external barriers.
• Identifies reasons for readmissions and collaborates with interdisciplinary team on strategies to reduce readmission rate.
• Appropriately identifies and refers cases to the physician advisor to support timely progression of patients along the continuum of care and (appropriate) discharge planning.
• Interacts with patient/family to discuss plan of care and coordination of services based on clinical needs and available resources.
• Utilization Review: Maintains a working knowledge of the UR requirements of each payor within the patient population; Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion.
• Works collaboratively with physicians and managed care companies on concurrent denial appeals.
• Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor.
• Discharge Planning: Responsible for assessment, communication and monitoring of discharge planning process (The clinical nurse initiates the discharge planning process on admission).
• Obtains authorizations from managed care companies for post-discharge services.
• Affirms for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement.
• Liaison with financial department for current insurance coverage.
• Collaborates and participates in the appeals process with all members of the interdisciplinary team.

Qualifications

• Bachelor's Degree in Nursing; Masters preferred.
• Previous experience as in homecare, long term care or utilization review preferred.
• Discharge Planner or Case Manager preferred.
• Manager or a minimum of 3-5 years' experience as a RN in an acute care setting.
• Current NYS RN nursing license.
• CCM certification preferred.
• Re-credentialing of CCM status expected.
• PRI Certification (to be obtained within 1 year).