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We have an exciting opportunity to join our team as a Care Manager, focusing on utilization management.
In this role, the successful candidate Coordinates, negotiates, procures, and manages the care of patients by providing focused care coordination across the acute care continuum. Evaluates appropriate clinical resource utilization, and assesses patients for transitioning to the next appropriate level of care through review of patient records and information derived from interdisciplinary rounds. Collaborates with the health care team to ensure the achievement of quality outcomes for patients/families
- Identifies cases that require peer review in accordance with the clinical indicators and criteria developed by the clinical department. Identifies trends in care, processes or services that may provide opportunities for improvement in a patient population or clinical service. Refers appropriately cases that require peer review in accordance with the clinical indicators and criteria developed by the clinical department. Takes initiative to participate in a quality/process improvement initiative. Collaborates with the interdisciplinary team to create solutions and take corrective actions to address issues resulting in variances in the plan of care.
- Uses evidence-based practice to drive improvement strategies. Promotes health care outcomes in conjunction with evidence-based guidelines. Identifies areas requiring further study. Develops strategies to utilize data findings for individual patients as well as program. Recommends interdisciplinary evidence-based practice changes.
- Participates in development of quality indicators and analysis of such indicators per departmental quality & performance improvement plan. Collaborates with members of the interdisciplinary team to develop quality indicators to measure performance improvement per departmental quality & performance improvement plan. Conducts required and initiated monitoring activities report to respective disciplines as indicated. Evaluates outcomes of monitoring, and adjusts targets and reporting as indicated. Facilitates and ensures sharing of data and outcomes with interdisciplinary team.
- Contributes to the development of new strategies to address transitional planning needs of specific assigned patient populations, improved care coordination and care management delivery. Utilizes current literature to facilitate clinical/care management practice changes. Participates in the development and revision of clinical/care management practice standards. Engages in strategies to measure improvements in quality of care that directly result from care management interventions. Utilizes evaluative and outcomes data to improve care management services.
- Communicates information documented in the medical record that identifies a potential event/occurrence to the Risk Manager. Identifies quality and risk management issues; refer issues for corrective action as appropriate. Documents a potential event/occurrence and communications to the Risk Manager into Canopy within established timeframes.
- Evaluates appropriateness of alternate level of care for optimal delivery of services to the patient and for resource efficiency. Assesses the need for continued acute care services. Anticipates barriers to discharge. Assesses and re-assesses appropriate discharge plans and options based on clinical need and patient/family resources. Collaborates with other members of the interdisciplinary team to dual plan discharge options. Facilitates patient/family team meetings to discuss discharge plan and options.
- Promotes own professional growth and development in care management role. Identifies own practice abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self development. Participates in and utilizes peer review to identify areas for improvement in practice and leadership. Achieves previously established personal professional goals. Participates in departmental education sessions.
- Maintains current clinical knowledge in area of review and patient population. Achieves and maintains current professional licensure, national certification, and/or higher education in case management or in a health and human services profession directly related to case management practice. Maintains continuing competence appropriate to case management and to professional licensure or professional certification. Provides only case management services within scope of practice. Refers patient to another source for services outside scope of practice. Maintains continuing competence appropriate to case management and to professional licensure or professional certification. Maintains annual mandatory education requirements. Maintains membership in professional organizations.
- Participates in development and implementation of appropriate patient/family education material pertinent to population served. Contributes to the development of patient/family education material for disease management. Facilitates patient/family education and understanding to prevent risk behaviors and to promote and achieve good health outcomes. Educates the patient/family and provide support in moving toward self-care. Educates and assists in facilitating patient/family access to necessary and appropriate health care services.
- Serves as resource for education of patients, families, peers, staff and physicians. Facilitates patient/family teaching as soon as learning needs are identified. Provides patient/family education regarding post acute services, community resources or other as needs identified. Role models expert professional care management practices. Supports a constructive environment of learning and development of mutual respect with health care team and peers. Facilitates staff access to outside educational opportunities through sharing of program announcements, etc.
- Facilitates patient/family knowledge of and participation in the plan of care. Identifies long and short term needs based on a comprehensive assessment and anticipate outcomes. Proactively identifies hospital services and available resources to meet the patients needs. Ensures that patients individualized plan of care is collaborative and multidisciplinary by working with patient, physician, and health care team members. Focuses the care plan on quality of life, effective utilization of resources, and facilitates goal achievement and movement through the continuum of care. Collaborates with patient/family, physician, and health care team for final agreement with treatment goals, timeframes and coordination of care. Develops additional and contingency plan options with patient/family when planning for discharge.
- Educates nursing, medical and ancillary staff about care management role, relevant clinical criteria and resources available for patients, as well as regulatory and managed care requirements. Demonstrates an understanding of the vision and goals of the care management program. Demonstrates an understanding of the core functions of the care management role. Demonstrates an understanding of and effectively communicates information relative to clinical criteria and resources available for patients/families to the healthcare team. Serves as a resource for other members of the health care team by participating in or conducting formal/informal in-service education as needed. Identifies own practice abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self development.
- 10. Participates in departmental, interdisciplinary, hospital and Medical Board committees as appropriate. Participates in departmental, interdisciplinary, hospital and Medical Board committees as requested. Represents the voice of Care Management in committee participation. Completes committee assignments as requested. Provides feedback and periodic reports to Care Management at departmental meetings and senior managers on relevant issues.
- Acts as advocate/facilitator in all cases with insurance related issues, delays in treatments and/or diagnostic tests. Collaborates with the interdisciplinary team to maintain appropriate levels of care to facilitate movement of the patient through the continuum. Identifies and documents delays in treatment and processes. Understands basic reimbursement systems and identifies potential payor issues relative to delays in treatments and/or diagnostic tests. Assists in developing strategies to decrease avoidable days. Demonstrates and communicates the value of avoidable days and/or additional documentation to justify acute inpatient hospitalization.
- Communicates the outcome of chart review and managed care company telephonic review with the health care team as appropriate. Conducts accurate reviews using CMS, Milliman Care Guidelines and the patients chart as the primary source of information. Performs and documents initial certification and continued stay reviews within appropriate time frame and in appropriate system. Documents obtained payor authorization in a complete, timely and concise manner. Maintains follow-up communication with payor as required for authorization of hospital stay. Notifies health care team of outcomes of communication with payor and authorization status. Notifies departmental manager of all unresolved utilization problems/issues.
- Coordinates discharge appeals or issuance of Hospital Notices in accordance with State and Federal Regulations and departmental guidelines. Demonstrates an understanding of the CMS and NY State regulations for discharge appeals and issuance of Hospital Notices. Follows procedures for issuing Hospital Notices when appropriate and communicate necessary information to healthcare team relative to patients benefits. Facilitates issuance of the Important Message from Medicare within 24 48 hours before discharge and the Detailed Notice of Discharge if indicated. Effectively communicates the initiation of a discharge appeal to the health care team. Coordinates the collection of medical record documentation for review by the review agent (i.e., IPRO, managed care carrier). Communicates outcome of discharge appeal to patient/family and health care team.
- Effectively communicates information relative to a potential denial to the appropriate members of the health care team. Communicates timely, complete, and accurate information relative to a potential denial to the appropriate members of the health care team. Demonstrates an understanding of the peer-to-peer appeal process for authorization of acute inpatient hospitalization. Effectively monitors, documents and informs members of the health care team the outcome of the peer-to-peer appeal process. Demonstrates an understanding of CMS, Milliman Care Guidelines relative to the patients diagnosis and condition when providing a clinical review to the payor to prevent a potential denial. Effectively communicates the impact on reimbursement to the hospital for potentially denied days to the health care team. Utilizes the chief of service/physician advisor per departmental guidelines.
- Ensures identification of variances and the development of appropriate contingency plans for each phase of care in the event of patient health complications or systems barriers. Communicates with the attending physician/hospitalist, patient/family and staff regarding alteration in plan. Monitors test results, patient responses to interventions, health status and makes recommendations for revisions to treatment plan based on patient need and responses. Evaluates and communicates changes in patients clinical condition timely. Documents medical plan of care and reflects patients progress in meeting prescribed plan.
- Facilitates timely and appropriate communication among attending physicians, nurse practitioners, physician assistants, patients, family members, other members of the health care team, external providers and payers. Refers significant clinical issues per protocol to the attending physician and/or hospitalist or to the designated consultants. Utilizes chief of service/physician advisor to address unresolved clinical and interdisciplinary issues. Participates and contributes as a regular member of interdisciplinary rounds to communicate and receive pertinent information. Utilizes critical thinking skills and assists others to identify and resolve potential and existing problems related to coordination of patient care. Determines the best method to communicate with the interdisciplinary team about different kinds of issues (i.e., direct contact, telephoning, emailing, and paging). Collaborates with attending physician/hospitalist regarding patients achievement of therapeutic regimen.
- Facilitates effective coordination of interdisciplinary unit/physician team (e.g., Firm on the Medical Service) rounds to identify the patients clinical management needs, progression of care, identification of barriers, appropriate discharge plan and anticipated discharge date. Assumes a leadership role to coordinate and facilitate daily interdisciplinary unit/physician team rounds, LOS management and discharge process. Collaborates with the interdisciplinary team to maintain appropriate levels of care to expedite the movement of the patient to alternate levels of care throughout the continuum. Reviews, monitors and individualizes on an ongoing basis, each patients plan of care based on diagnosis and assessment of patient/family needs. Identifies internal obstacles to efficiency and good patient outcomes and intervenes with healthcare team to eliminate when possible. Identifies a follow-up time frame to accomplish the recommended plan. Communicates patient status and needs to the next level of care for discharge planning.
- Supports the mission, philosophy, standards, goals and objectives of NYU Hospitals Center and Care Management Program. Contributes to the development of the goals and objectives of the Care Management Program consistent with the objectives of NYU Hospitals Center. Understands, applies and supports departmental/hospital policies, procedures and standards. Observes at all times legal and ethical considerations pertaining to patients and hospital personnel. Initiates programs for improving cost effectiveness in coordination of patient care. Assists managers to create a participative environment in department based meetings and other activities. Analyzes and develops systems to improve processes and outcomes in collaboration with managers.
- Applies customary protocols, pathways, evidence-based processes and other means of managing patient care. Utilizes protocols, pathways and order sets to formulate, communicate and ensure implementation of the patient plan of care. Utilizes multidisciplinary team to address individualized patient needs. Develops realistic goals with multidisciplinary team for patient to achieve milestone activities within appropriate timeframes. Demonstrates flexibility with plan of care to meet patient needs..
- Documents assessments, findings, progress, interventions and recommendations in a care management software system and/or medical record according to established standards. Documentation meets standards in accordance with departmental and hospital policy and procedures. Documents assessments, findings, progress, interventions and recommendations in Canopy and ECIN Care Management and ICIS systems within established timeframes. Documents revisions in diagnoses, plan of care and outcomes. Documents patients responses to interventions with appropriate consideration of patient confidentiality.
- Assesses patient and family responses to interdisciplinary plan of care and care management interventions, and adapts interventions to achieve optimal outcomes. Collaborates with patient, family, interdisciplinary team for agreement with treatment goals, timeframes and coordination of care. Works with the interdisciplinary team to facilitate adjustments to the care plan to promote enhanced outcomes. Intervenes as care manager in a manner that is consistent with the established plan of care. Prioritizes and organizes interventions. Implements interventions in a safe, timely and appropriate manner.
- Works collaboratively with attending physician, consulting physician(s) and other disciplines to identify, develop, implement and coordinate an appropriate plan of care that maximizes individual patient/family preference and enhances quality, access, and cost-effective outcomes. Ensures patients individualized plan of care is collaborative and multidisciplinary by working with patient/family, attending physician/hospitalist and health care team members. Coordinates care based on individual needs, expected goals and length of stay. Facilitates interdisciplinary plan of care interventions. Communicates effectively with attending physician/hospitalist and members of health care team to enhance patient care in a positive environment.
- Formulates the plan of care, along with the patient and family, based on communication with the attending physician(s), expected goals of care and length of stay; articulates knowledge of the plan of care through an understanding of patients diagnosis, prognosis, care needs, and desired outcomes. Considers assessment findings and collaborates with the attending physician (s)/hospitalist to establish the expected goals of care and LOS. Collaboratively participates in the development of an interdisciplinary plan of care that is individualized to the patients condition or needs. Focuses the care plan on quality of life, effective utilization of resources, and facilitates goal achievement and movement through the continuum of care. Proactively identifies hospital services and available resources to meet patients needs. Reviews patient history and re-assess prognosis and care needs to achieve desired outcomes. Assesses patient/family needs for advance care planning. Confers with attending physician/hospitalist and health care team regarding variances from anticipated plan of care.
- Performs systematic assessment and reassessment of patient and family/significant other considering clinical presentation, cultural and religious influences, individual experiences, available resources, environmental factors as well as health behaviors and practices. Considers all aspects of patient/family assessment findings. Understands medical plan of care and is able to communicate pertinent findings from patient assessment. Monitors medical plan of care to determine outcome of treatment and revise patient assessment as necessary. Facilitates appropriate consults based on patient assessment to ensure timely delivery of care. Identifies cultural and religious influences on illness.
- Assesses patient and medical record documentation for appropriate acute admission and level of care, quality and safety indicators, and plans for discharge. Assesses patient and medical record documentation to identify medical necessity and appropriateness of admission and continued stay using pre-established clinical criteria (i.e., Milliman Care Guidelines, CMS) according to hospital policy. Ensures that the physicians documentation supports level of care. Collaborates with physician when additional documentation needed to support level of care. Communicates appropriate level of care to the health care team. Utilizes patient assessment information to identify quality and safety indicators to monitor during hospital stay. Performs initial and ongoing assessment of patient/family needs for discharge planning and communicates findings to interdisciplinary team.
To qualify you must have a Licensure: Professional Registered Nurse in New York State with current registration. Education: BSN required, or graduate of an accredited RN program with BS in related health care field. Experience: Three to five years clinical experience, acute medical-surgical preferred, or in the care of the population to be care-managed. Utilization Management experience preferred. Competencies: Evidence of excellent interpersonal skills, effective communication, negotiation and conflict management skills; creative problem solving and clinical leadership; change management, organizational and time management skills. Ability to apply critical thinking and clinical expertise toward achievement of specific outcomes. Previously demonstrated ability to foster strong collaboration with co-workers, peers, physicians, nursing, and ancillary departmental support staff. Knowledge of Microsoft Office and demonstrated proficiency in managing software such as Eclipsys Sunrise Manager, Canopy, and ECIN.
Required Licenses: Registered Nurse License-NYS
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.
NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
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