Strength Through Diversity
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Dept Name- Case Management
Job Title: Case Manager
Roles & Responsibilities:
The Case Manager (CM) will be responsible for all aspects of case management for an assigned group of inpatients to determine the appropriateness of the admission and continued stay, assist in the development of the plan of care; ensure that the plan is implemented in a timely basis and identify the expected length of stay (ELOS). The CM works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed. The CM actively participates in specific clinical initiatives focused on reducing the length of stay (LOS), improved efficiency, quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services
Essential Duties and Responsibilities
- 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.
- 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.
- Case 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)
- 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.
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression.