As Case Manager you will facilitate the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education and resource management. You will also collaborate with service providers to link patients with appropriate providers and resources throughout the continuum of health and human service and care settings and ensure safe, effective, patient centered, timely and efficient patient care.
- Access to care and services
- Performs initial clinical screening for medical necessity and determines level of care placement.
- Collaborates with interdisciplinary team members to facilitate care coordination and delivery.
- Develops a comprehensive case management plan including projected LOS to address identified needs.
- Screens admissions for palliative care triggers and refers for consult.
- Collaborates with Physician to ensure documentation substantiates medical necessity for admission.
- Evaluates patients not meeting criteria for admission against services available through post acute network and coordinates referrals to those services, as required.
- Coordinates and reviews all transfers into hospital for appropriateness and payment source.
- Identifies patient readmission and the contributing factors.
- Ensures completion of all consults in an efficient manner.
- Identifies Condition Code 44 patients and follows established policies and procedures.
- Identifies and issues HINNs for admission denials and IPRO issues.
- Complies with all federal, state and local regulations as related to provision of acute care services.
- Delivery of care
- Consults with Physician to coordinate response for concurrent denials.
- Conducts concurrent clinical screening for continued stay and level of care appropriateness, including ALC designation.
- Assumes leadership role in daily multidisciplinary rounds, communicating with physicians, nurses and other tam members regarding resource utilization, LOS, level of care and post acute placement.
- Reviews patient progress against established plan of care and modifies plan as required to achieve LOS goals.
- Evaluates clinical resource utilization against evidence based practice guidelines and resolves system issues impeding diagnostic or treatment progress.
- Manages LOS based on working DRG. Documents avoidable delays and facilitates multidisciplinary care team involvement to expedite plan.
- Assists in the development of the educational plan to ensure the patient/family needs are met.
- Reviews clinical documentation to ensure medical record supports level of care.
- Identifies quality concerns and escalates as appropriate.
- Coordinates patient care across inpatient units and throughout the continuum to reduce fragmentation of care.
- Refers patients to social work services who require intervention including but not limited to emotional support, protective services, shelter placement and substance abuse or psychiatric placement.
- Consults with Medical Director of Utilization as necessary to address and resolve issues regarding medical necessity, throughput, discharge planning or quality.
- Collaborates with multidisciplinary care team to identify discharge date, discharge plan and expected LOS and communicates plan to patient/family.
- Manages the patient discharge plan and facilitates multidisciplinary care team involvement to expedite, as required.
- Coordinates post acute services, ensures necessary authorizations are obtained per payer requirements and communicates information to patient/family.
- Ensures patient is prepared for transition to post acute setting discharge notice has been provided to patient and family and discharge paperwork is complete. Coordinates community referral/ support services, as indicated.
- Performance Improvement
- Participates in data collection and variance analysis.
- Uses data to drive decisions and plan/implement performance improvement strategies related to patient flow, throughput and utilization across the continuum.
- Bachelors Degree in Nursing, required. Masters Degree, preferred.
- Current license to practice as a Registered Professional Nurse in New York State.
- Patient Review Instruments (PRI) Certification and Case Management Certification, preferred.
- Minimum of one (1) year related experience, required, Utilization Review/Discharge Planning experience, preferred, or completion of NSLIJ Care Coordination Extern Program, required.
- Demonstrates positive and professional written, verbal and non verbal communication skills.
- Knowledge of regulatory and survey standards (IPRO, Joint Commission, Department of Health, CMS).
- PC literate. Knowledge of Microsoft Office, Excel spreadsheet management required.
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing our customers with the highest quality service, we stand behind our core values: Patients first; Caring; Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.