Nurse Case Manager

1 month ago

Poughkeepsie, New York, United States Nuvance Health Full time
Job Summary

Nuvance Health seeks 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.

Key Responsibilities
  • Provide clinically-based case management to support the delivery of patient care
  • Pace cases from physiological and economic perspectives
  • Have overall accountability for utilization management and transition management for patients within the assigned caseload
  • Partner with Social Workers and collaborate with other healthcare team members to identify appropriate utilization of resources and ensure reimbursement
  • Utilize criteria to confirm medical necessity for admission and continued stay
  • Create discharge plans appropriate to the patient's needs and resources
  • Determine medical necessity, appropriateness of admission, continuing stay, and level of care using a combination of clinical information, clinical criteria, and third-party information
  • Intervene when determinations are not in alignment with clinical information, clinical criteria, computer system, or third-party information to resolve the situation
  • Document information in the current electronic system
  • Validate admission and continuing stay criteria with third-party payers and primary care and attending physicians
  • Recommend alternative care sites where appropriate
  • Collaborate with third-party payers to anticipate denial of payment and proactively address issues contributing to a potential denial
  • Intervene to prevent denial where possible
  • 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 patients and families for continuing care needs to develop, implement, and evaluate an effective discharge plan in collaboration with the multidisciplinary team
  • Use knowledge of usual length of stay to initiate a plan for discharge
  • Collaborate and communicate with patients/families related to reimbursement issues and create a discharge plan
  • Support the process of patient choice in establishing a discharge plan
  • Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes
  • Communicate and coordinate with the patient/family and healthcare team to intervene when progression is stalled or diverted
  • Address actual/potential barriers to discharge
  • Provide support and counseling to patients/families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnoses, changes in living situations, and bereavement
  • Establish a plan and document interventions and outcomes
  • Complete interventions necessary for discharges to home with self-care, home with services, and short-term skilled nursing facility placement
  • Assemble 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
  • Complete and disseminate all necessary legal and clinical documentation as required
Requirements
  • 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 be able to work independently and prioritize work
  • Must be able to 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
  • Minimum 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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