Nurse Case Manager
2 weeks ago
Nuvance Health is seeking a skilled Nurse Case Manager to join our team at Vassar Brothers Medical Center. As a key member of our Care Coordination department, you will play a vital role in ensuring the delivery of effective and efficient patient care.
Job SummaryUnder the general supervision of the Director, the Nurse Case Manager will provide clinically-based case management to support the delivery of effective and efficient patient care. This includes pacing the case from physiological and economic perspectives, utilizing criteria to confirm medical necessity for admission and continued stay, and collaborating with the healthcare team to identify appropriate utilization of resources and ensure reimbursement.
Responsibilities- Determine medical necessity, appropriateness of admission, continuing stay, and level of care using a combination of clinical information, clinical criteria, and third-party information.
- Validate admission and continuing stay criteria with third-party payers, primary care, and attending physicians, recommending alternative care sites when appropriate.
- Collaborate with the third-party payers to anticipate denial of payment and proactively address issues contributing to a potential denial.
- Support the effective prevention and management of denials, including providing information as part of the appeal process.
- Serve as the lead in obtaining financial and other resources for patients/families in need.
- Assess the patient and family for continuing care needs to develop, implement, and evaluate an effective discharge plan in collaboration with the multidisciplinary team.
- Collaborate and communicate with patients/families related to reimbursement issues and create a discharge plan, supporting patient choice in establishing a discharge plan.
- Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes, communicating and coordinating with the patient/family and healthcare team to intervene when progression is stalled or diverted.
- Provide support and counseling to patients/families experiencing and/or anticipating issues adjusting to illness, catastrophic diagnoses, changes in living situations, and bereavement, establishing a plan and documenting interventions and outcomes.
- Complete interventions necessary for discharges to home with self-care, home with services, and short-term skilled nursing facility placement, assembling necessary referrals, discharge summaries, and pertinent information for placement prior to the day of discharge.
- Consult, assess, refer, coordinate interventions in cases of suspected or actual situations of child or adult abuse and neglect or other forms of domestic violence and/or sexual abuse.
- Actively contribute to and participate in length of stay meetings, discharge planning rounds, during unit daily report, clinical practice teams, and department meetings.
- Identify high-risk patients and create a collaborative plan to address their unique needs.
- Serve as the lead in obtaining legal guardianship and competency determinations as well as adoption-related situations, completing and disseminating all necessary legal and clinical documentation as required.
Must have strong interpersonal and communication skills, ability to form positive, collaborative relationships with hospital staff, patients, and families. Ability to effectively negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in obtaining solutions to problems. Must be able to work independently and prioritize work, manage multiple priorities. Basic knowledge of computers and clinical applications. Ability to problem-solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge. Ability to effectively negotiate with internal and external providers of patient care services. Language: Ability to speak and write English to the extent necessary for safe and efficient performance of the job.
Education and ExperienceMinimum Requirement: 3 years experience in acute care. Must have Associate's Degree or BSN preferred. Must have current RN license. Preferred experience in Utilization Review/Management.
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