RN Care Manager

Position Summary

The RN Care Manager performs the initial comprehensive assessment on admission in accordance with the Care Management Department policy, screening all patients by utilizing established tools for high risk indicators (i.e. AIMS, Geisinger, polypharmacy) to ensure high risk patient populations receive the appropriate supportive services for discharge to prevent readmission and assess all populations for potential discharge planning needs. Provides ongoing reassessment of needs throughout the hospital course. Performs UR activity per department policy.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors
2. Completes a comprehensive initial assessment.
3. Performs all activities for multidisciplinary care coordination at the intra-hospital level of care and inter-hospital level of care.
4. Performs all transitional planning activities including but not limited to:
   • Patient/caregiver education
   • Arrangement of all aftercare
   • Commercial payer involvement
   • High utilizer patient root cause
5. Communicates and collaborates all relevant patient information to appropriate health team members.
6. Ensures department goals of LOS reduction, readmission prevention, denial reduction, and satisfaction improvement are realized.
7. Documents per department requirements.
8. Participates in Performance Improvement activities as needed.
9. Performs all UR activities per department policy:
   • Commercial payer reviews
   • Disposition determination,
   • Retro/self-audit
   • MC variance
   • Admission clinical review.
10. Performs all other related duties as assigned

Education & Experience Requirements

• BSN or related Bachelor's degree required
• 5 years clinical ED, critical care or med/surg experience required
• Previous case management experience preferred
• Knowledge of healthcare financial, regulatory, and payer issues preferred
• Knowledge of state, local, and federal programs strongly preferred
• Experience in use of Milliman/InterQual criteria
• Registered Nurse (RN) NYS license required
• PRI/Screen certification strongly preferred.
• C.C.M. (Certified Case Manager) certification preferred
• Computer skills essential