Case Management Nurse

One Brooklyn Health•New York, NY

About The Position

The role of the Case Management Nurse coordinates and directs the patient care case management strategies to ensure quality care and efficient use of resources. Provides for staff management and leadership in departmental planning and policy development.

Requirements

Minimum BSN in Nursing degree required.
Current NYS Registered Nurse licensure.
Minimum of three (3) years clinical experience in an acute care setting. Critical care experience preferred.
Minimum of three (3) years prior Utilization Review/Case Management/Discharge. Planning/Quality Planning experience a must.
PRI certification required.
Knowledge and experience in utilizing MCG and Interqual criteria a must.
Ability to communicate effectively in English both verbally and in writing.
Knowledge of Federal, State and JCAHO guidelines for utilization review, discharge planning/quality assurance/infection control.
Knowledge of Milliman guidelines and Interqual criteria.
Understanding EPIC and the integration with INDICIA/CareWebQI.
Involves standing, walking, sitting, talking, hearing and bending.
May include some repetitive motions.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

Responsibilities

Assists in the development of the clinical pathways for assigned DRG’s in cooperation with medical and nursing staff.
Reviews the management of care by all care givers against the clinical pathway. Identifies, documents variances and determines justification and appropriateness of same. Takes appropriate action.
Conducts care management reviews effectively and takes appropriate action for all deviations that neither do nor meet criteria/or without justification.
Screens for quality, appropriateness and practitioner performance, using pre-established criteria. Makes appropriate referrals.
Conducts focused reviews as assigned. Prepares and submits timely and accurate reports on same assigned.
Actively participates in multi-disciplinary conferences for patients with special needs/problems. Provides information such as DRG LOS to other disciplines for timely discharge planning.
Provides timely clinical reviews to Third party Payers utilizing Milliman guidelines and Interqual criteria.
Coordinates the discharge appeal process accurately and timely when applicable.
Serves as resource/consultant to clinical departments regarding case management issues of policies.
Notifies Physician Advisors of need for review.
Prepares and presents accurate reports and serves on committees assigned.
Participates in the evaluation of UR, Discharge Planning, and QA programs annually and assists in strategic planning activities for the department.
Conduct orientation and in-service programs for topics related to the department on a unit level.
Collects QA data relative to the physician credentialing/re-appointment process. Collects data for employees practices patterns and refer same to appropriate department.
Recommend policies/procedures/standards/for the department.
Supervises proper level of care assignment.
Completes and submits ALC notices, PRI’s, HINN’s and reinstatement notices, accurately and timely as indicated.
Maintains competency through attending seminars, regarding job related topics.
Performs other duties as required.