Nurse Case Manager: E8: Rehab

3 weeks ago

Kinderhook, New York, United States Albany Medical Center Full time
Job Summary

Albany Medical Center seeks a skilled Nurse Case Manager to join our team in Inpatient Rehab - E8. As a key member of our interdisciplinary team, you will be responsible for coordinating patient care across the continuum of care, ensuring timely and appropriate interventions to achieve optimal patient outcomes.

Key Responsibilities
  • Collaborate with the admission MD and interdisciplinary teams to ensure coordination of care across the continuum of care.
  • Proactively monitor patients' clinical process through patient care standards and evidence-based guidelines to ensure timely and appropriate interventions.
  • Provide collaborative care management with the primary nurse in assessing for discharge planning needs, coordinating appropriate resources, and evaluating the effectiveness of the discharge plan.
  • Collaborate with the healthcare team and appropriate departments in the management of care across the continuum of care, including pre-admission, discharge, post-discharge, planning length of stay, and utilization of resources.
  • Utilize your special body of knowledge and evidence-based guidelines to provide leadership and guidance to the healthcare team in formulating an individualized multidisciplinary plan of care.
  • Facilitate and participate in healthcare team care conferences for patients with complex problems.
  • Facilitate patient and family education and the discharge process to promote continuity of care and optimal patient outcomes.
  • Demonstrate experience in the referral process and use of community resources.
  • Review data from admission screening to clarify admission diagnosis, establish appropriate length of stay, and identify any potential outliers and determine appropriateness of admission based on institutional standards and evidence-based guidelines.
  • Contact payer sources to confirm/negotiate benefits and provide concurrent reviews.
  • Identify capitated patients to determine appropriate utilization of services and coordinate post-hospital care using defined standards.
  • Identify high-risk patients based on clinical and financial criteria for collaboration with patient financial services to problem-solve available resources.
  • Ensure that appropriate medical/legal documentation is contained in patient records.
  • Comply with regulations established by third-party payers, including but not limited to notices of non-coverage reinstatement and continued stay.
  • Collaborate with the healthcare team in implementing strategies to reduce length of stay/resource consumption to optimize patient health status for assigned service patients.
  • Assess educational needs and provide learning opportunities for healthcare professionals relevant to particular cases and selected patient care groups.
  • Collaborate with case management leadership to compile and report aggregate variances and data for specific patient care services.
  • Communicate and analyze aggregate variances with members of the healthcare team and develop strategies for variance reduction.

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