Case Manager

2 days ago


Bronx, New York, United States MONTEFIORE MEDICAL CENTER Full time
Job Title: Case Manager - Wakefield

The Case Manager, RN, plays a critical role in coordinating medical care services for patients. This includes ensuring efficient utilization of resources, delivering high-quality patient care, and maintaining compliance with relevant regulatory, accrediting, and contractual requirements.

Key Responsibilities:
  • Assess the appropriateness of patient care services
  • Prepare and submit clinical appeals for denied claims
  • Compile and analyze data to support utilization reviews, quality improvement initiatives, and other areas as assigned
Requirements:
  • BSN or a bachelor's degree in a related field required, Master's preferred
  • NYS RN License required
  • PRI assessor number required prior to end of 3-month probationary period
  • 3-5 years recent acute care clinical experience preferred
  • Experience in utilization management preferred
  • Experience in a managed care organization preferred
  • Certification in Utilization Review or Case Management preferred
  • Analytical skills, problem-solving skills, conflict resolution and negotiation skills
  • Demonstrated knowledge of federal, state and commercial/third-party regulations related to utilization management functions, discharge planning and associated processes
  • Demonstrated knowledge of quality/performance improvement tools and techniques
  • Demonstrated knowledge of utilization and case management principles
  • Experience in the application of utilization management decision support criteria preferred
  • Computer skills including data entry, word processing, and electronic messaging
  • Experience in the use of Windows-based software applications
  • Experience in the use of an electronic clinical information system preferred
  • Excellent verbal, written and interpersonal communication skills, as well as a commitment to interdisciplinary teamwork
  • Excellent organization skills, teamwork skills and time management skills
  • Expert clinical knowledge of disease processes to identify care needs
  • Understanding of the health care delivery system and its sites of care, delivery models, and the roles of various providers and health care professionals
  • Experience in interpreting and applying benefit coverage rules and assessing coordination of benefits guidelines and managed care regulations required

Mission: To heal, to teach, to discover and to advance the health of the communities we serve.

Vision: To be a premier academic medical center that transforms health and enriches lives.

Values: Humanity, Innovation, Teamwork, Diversity, Equity


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