Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Dept Name- Utilization Management
REQ # 84367
Job Title: Case Manager
Roles & Responsibilities:
- Review and advice for appropriate level of care using criteria sets (refer to designated site software), cases referred or who have Observation diagnosis, or other high risk diagnosis as well as readmissions.
- Review all patients in RETU to insure they meet Observation criteria, assist with discharge or admit to next LOC with-in unit specified timeframes.
- 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.
- Oversee clinical throughput of patient, ensuring medical treatment plan, e.g., timely tests, consults.
- Collaborates with Physicians and other clinicians to expedite diagnostic testing, treatment and consultations.
- Documents all clinical reviews
in using designated site software program.
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.
- Liaison with Physician Advisor.
- 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.
- Determine ALC status and track avoidable days.
- 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.
- 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.
- Performs additional duties as assigned.
- Responsible for assessment, communication and monitoring of discharge planning process in collaboration with the clinical nurse initiates the discharge planning process on admission.
- In collaboration with Social worker, 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.
- Assist in having appropriate staff complete discharge forms in a timely manner.
- Coordinates the Discharge Appeal process
- Liaison with financial department for current insurance coverage.
- Collaborates and participates in concurrent denial and appeals process with all members of the interdisciplinary team.
Communication and Collaborative Relationships
- Develops and maintains effective working relationships with interdisciplinary team and with managed care/community organizations.
- Interfaces with other departments within the Hospital effectively.
- Demonstrates a professional, courteous and respectful attitude in dealing with patients/families/care givers and members of the health care team
- Educational/Professional Development
- Participates in the development of unit based staff.
- Meets regulatory, licensure and annual health assessment requirements.
- Identifies own learning strengths and needs through ongoing self assessment
- Utilizes learning resources.
- Seeks educational opportunities to maintain and enhance competence within current advances in health care delivery and case management
- Provides presentations and educational offerings as needed.
- Participates in special projects and committees.
- Attends relevant workshops, conferences and seminars
- Demonstrates membership in professional and related organizations.
- Demonstrates competence in case management and required information technology and systems.
- Bachelor of Science with a major in nursing preferred. Associate degree in nursing is considered only with relevant experience and/or active matriculation in a BSN Program if approved by Chief Nursing Officer or designee
- Licensed as a registered nurse with current registration in New York State
- Acute Care Nursing Experience preferred.
- BLS certification required
- Relevant clinical competence in area of nursing practice assigned; new graduates must possess current knowledge of the nursing process and its application
- Evidence of ability to maintain interpersonal relationships, communicate appropriately to others, and work effectively and efficiently to solve problems
- Demonstrates the ability to work in a team displaying effective communication and critical thinking
- Ability to read, write, understand and speak English in a clear and concise manner
- Visual, physical, auditory and cognitive ability to assess patient status
- Physical and mental health necessary to care for acutely ill patients with a broad variety of diagnoses and behaviors on a daily basis
- Ability to walk, stand, lift, stoop, push and respond quickly in a variety of situations and for an extended period of time
- Manual dexterity to perform a variety of clinical procedures relevant to practice area (i.e. venipuncture, urinary catheterization, cardiopulmonary resuscitation)
- Ability to use basic data entry, retrieval systems and the electronic medical record documentation system in a proficient manner
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 promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.