DUTIES: The RN Case Manager and TH UR/AQ Senior Coordinator provides hospital case management, utilization review and discharge planning to ensure that patients progress through the continuum of care and are discharged through a well-coordinated transition of care plan. In addition, the candidate will: - Utilize standard review criteria, specifically the Milliman Care Guidelines, to justify level of care, medical necessity, expected length of stay, and intensity for inpatient admissions. - Review, plans and facilitates all aspects of patients' care planning, including care coordination and transition of care, utilization review and discharge planning. - Perform initial and concurrent clinical reviews for all assigned hospitalized patients using standardized care guidelines to determine medical necessity for inpatient admission or for placement in other appropriate level of care. - Promote interdisciplinary collaboration: Provide resources to the interdisciplinary team when appropriate on issues of medical necessity and clinical documentation requirements; Collaborate with Social Worker, the Department of Nursing and Physicians to discuss patient treatment plans and transition of care post-hospitalization. - Facilitate concurrent requests for reconsideration of potential denials; Coordinate peer interaction between SUNY UHB physicians and the managed care organizations physicians to prevent denial of reimbursements. - Complete Patient Review Instrument (PRI) as mandated by New York State for patients being discharged to a Skilled Nursing Facility, Sub-Acute Rehab or Nursing Home. - Support the initiatives, programs, process improvements and problem resolutions implemented by the Care Management Department. (DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION) QUALIFICATIONS: - Bachelor of Science Degree in Nursing. - Patient Review Instrument Certification. - New York State RN Licensure. - A minimum of 3 years direct patient care experience. - A minimum of 2 years Case Management or Utilization Review Management experience. - A minimum of 2 years discharge planning experience. - Ability to work with diverse patient populations with knowledge and sensitivity to cultural and spiritual influences influencing patient care. Preferred: - Graduate Degree in Healthcare. Additional Info: *Please ensure you include the 5-digit Line Number and Job Title in the subject line and body of your email submission.Closing Date: Open Until Filled STATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Internal Number: 53567
About SUNY Downstate Medical Center
SUNY Downstate's College of Medicine, Health Related Professions, Nursing and its School of Graduate Studies offer students a broad professional education that will prepare them for practice or careers in any location and community. This education provides exceptional opportunities for those students with a commitment to promoting health in urban communities and addressing the complex challenges of investigating and preventing diseases that confront clinicians, educators, and researchers in such an environment. This special aspect of Downstate's unique mission is reflected in the students it attracts and selects, the vast majority of whom are drawn from the New York City Metropolitan area. Many of these students are members of minority and cultural groups underrepresented in the health professions, and/or come from families of first-generation immigrants or from economically disadvantaged backgrounds.