Acute Care, Americans with Disabilities Act (ADA), Case Management, Certified Case Manager (CCM), Clinical Validation, Conflict Resolution, Content Management Systems (CMS), Data Management, Discharge Plans, Documentation, Healthcare, Hospital, Maintain Compliance, Medical Records, Nursing, Nursing Credentials, Organizational Skills, Patient Assessment, Patient Care, Patient Education, Primary Care, Quality Assurance, Registered Nurse (RN), Regulations, Team Player, Third-Party Payer, Time Management, Utilization Management
Job Description
Serves as liaison between the patient and facility/physician. Ensures a continuum of quality patient care throughout hospitalization and oversees provisions for patients discharge. Assesses, plans, oversees and evaluates the appropriateness of care throughout admission and hospitalization of the patient.
Job Responsibility
- Facilitates patient management throughout hospitalization.
- Performs concurrent utilization management using evidence based medical necessity criteria.
- Submits data to management regarding case management and/or quality initiatives.
- Serves as an in-patient liaison - planning, assessing, implementing and evaluating patient in collaboration with the health care team.
- Conducts chart review for appropriateness of admission and continued length of stay; Facilitates throughput.
- Conducts clinical reviews and interacts with third party payers to obtain approval of hospital days, pre-certification and post-discharge eligibility in relation to clinical course.
- Ensures compliance with current state, federal, and third party payer regulations.
- Documents the case management process in the medical record; completes and documents a care coordination assessment on the patient.
- Serves as a liaison to patient, family, admitting, primary care physician, health care team, and hospital departments.
- Completes applicable areas of the patients discharge instruction sheet and the patient transfer sheet; ensures case management documentation is current and accurate.
- Manage a caseload of adult inpatients, coordinating care from admission through discharge with confidence and clinical insight
- Engage in complex discharge planning, collaborating with interdisciplinary teams to ensure seamless transitions and continuity of care
- Partner with your team and coworkers to coordinate scheduling, supporting one another to maintain balanced and effective coverage
- Adapt and contribute across units by floating to areas of need, broadening your skills and strengthening department-wide care delivery
- Share in weekend and holiday rotations on an alternating basis, ensuring our patients receive consistent, high-quality support every day of the year through self-scheduling
- Performs utilization management using Milliman guidelines and assessing medical necessity criteria and conducts chart review for appropriateness of admission and continued length of stay; Facilitates throughput.
- Documents the case management process in the medical record; completes and documents a care coordination assessment on patients and ensures documentation is current, accurate, meets CMS guidelines and is in-line with our department and intuitional standard of practice
- Collaborates with interdisciplinary team including daily rounds, participation in family meetings, staff meetings
- Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
- Complete PRI's
- Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Job Qualification
Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred. Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
Emergency Department experience, preferred.
Knowledge of Milliman guidelines, preferred
Two years of experience in an acute care setting, preferred
Ability to manage a diverse caseload, including complex discharge planning needs
Strong time management, workflow, critical thinking and conflict resolution skills
Team-oriented; able to coordinate self-scheduling collaboratively
Flexible to float as needed
Flexibility in days as needed
Alternating weekends and holidays
Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team members base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).