DUTIES:The Case Manager will provide hospital case management, utilization review and discharge planning to ensure that the patient progresses through the continuum of care and is discharged through a well-coordinated transition of care plan.Utilized 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 the patient's care planning, including care coordination, utilization review and discharge planning. Perform initial clinical review and continued care review for all 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 physician to discuss patient treatment plan and transition of care post-hospitalization; Facilitate concurrent requests for reconsideration of potential denial; Coordinate peer interaction between SUNY UHB physicians and the managed care organization's 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; Address the denial of cases within the assigned unit and provide written appeal that will have a positive impact on final reimbursement decisions by payers; 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:REQUIRED: Bachelor's degree in Nursing. Patient Review Instrument Certification; New York State RN License; 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.PREFERRED: Experience in Denials and Appeals, Clinical Documentation Improvement and Disease Management.Additional Info: * Represents Location Pay for full-time appointees.Hours of work: 8:00AM - 4:00PM; Days of the week: Variable: Hours per week: 37.5Closing Date: Open Until FilledSTATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
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 o...f 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.