CASE MANAGEMENT NURSE

Overview

The role of the Case Management Nurse is responsible for coordination, and direction for the patient care case management strategies to ensure quality care, and efficient use of resources. The Case Management Nurse also provides for staff management, and leadership in departmental planning and policy development.

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 Payors 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 advisers 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.

Qualifications

Position Requirements:

• Minimum Bachelor of Science in Nursing (BSN) Degree required.
• Current New York State 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.

Language Skills:

• Ability to communicate effectively in English, both verbally and in writing.
• Good written and verbal communication skills.
• Good interpersonal skills a must.

Skills:

• Knowledge of Federal, State and JCAHO guidelines for utilization review, discharge planning/quality assurance/infection control.
• Knowledge of Milliman guidelines and Interqual criteria.
• Computer literacy a must and the ability to navigate word documents.

Physical Requirements:

• 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 without compromising patient care.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of Interfaith Medical Center (IMC).

IMC is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.