Mount Sinai Careers
Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
- Principle Duties and responsibilities include, but are not limited to:
- 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.
- Promotes an environment that is sensitive to cultural diversity and is open and responsive to the diverse backgrounds and experience of others.
- 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.
- Provides clinical information requested by the managed care companies in accordance with contractual agreements.
- 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 Medical Director as required.
- In psychiatry, the CM will document UR notes in the medical record as per OMH guidelines.
- 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.
- Assesses 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.
- Collaborative Relationships:
- Develops and maintains effective working relationships with interdisciplinary team and
- Case Managers within managed care organizations. Participates in nursing orientation.
- Interfaces with other departments in the Medical Center.
- Education Requirements:
Bachelor’s Degree in Nursing; Masters preferred.Experience Requirements:
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.Licensing and Certification Requirements:
Current NYS RN nursing license. CCM certification preferred. Re-credentialing of CCM status expected. PRI Certification (to be obtained within 1 year)
Microsoft Office - Intermediate
General Skills and Competencies:
- Ability to assess patient status
- Ability to work independently and collaboratively with the interdisciplinary team,
- patient/family, and others as appropriate. Ability to coordinate, prioritize and allocate resources
- Ability to use basic data entry and retrieval systems.