Care Manager - Readmission Specialist

Care Manager - Readmission Specialist

Position Summary

At Stony Brook Medicine the Care Manager – Readmission Specialist must have both hospital and transitional care experience. The Care Manager – Readmission Specialist identifies hospitalized patients who may be at a high risk for readmission. The RN following these patients must have good clinical and communication skills to address the needs of the patient and caregiver throughout their hospital stay.

Duties

Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

Duties of a Care Manager - Readmission Specialist may include the following but are not limited to :

• Identify high-risk patients and intervene with the support of the medical team to improve outcomes.

• Monitors and coordinate an interdisciplinary plan of care with the patient and their support team.

• Participate in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided to the patients.

• Documents the case management plans such as clinical needs, barriers, utilization of resources via assessments and/or progress notes.

• Help connect the patient with appropriate resources, facilities, and providers.

• Communicate with multidisciplinary patient care team and patients/families.

• Run reports and identify patients at a high risk for readmission.

• Advocating on the patient’s behalf to help ensure they receive appropriate care.

• Works to identify any social determinates of health issues, address them, document them, and look for available services.

• Help patients understand their medical conditions, treatment plans, and the importance of following medical recommendations.

• Follow patients telephonically post-discharge and assist with barriers to care

• Prior experience with Care Management or Utilization Management

• Understand levels of care including Inpatient, Observation, ED and Outpatient

• Understand the importance of readmission prevention and LOS reduction.

• Knowledge of high-risk readmission criteria.

• Understand insurance coverage and authorization.

• Effectively work with an interdisciplinary team regarding transition of care including Case Managers, Social Workers, Pharmacists, Medical staff, Nursing, Physical Therapist, etc.

• Active participation in rounds

• Gather and document all necessary encounters with the patient and/or patients’ family.

• Track and trend data with analysis of information.

• Actively involved in performance improvement activities including program development and improvement, data collection and analysis

• Adheres to all State and Federal requirements, RN license, JACHO, CMS and DOH regulations.

• Maintain high level customer service.

• All other duties assigned as needed

Qualifications

Required Qualifications:

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• _ Bachelor’s degree with 3-5 years CM experience

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• _ NY RN License

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• _ Acute hospital experience

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• _ Transitional experience

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• _ Experience with post-acute care coordination, including acute rehab/skilled nursing.

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• _ Computer proficient in Electronic Medical Record applications

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• _ Demonstrate knowledge of discharge planning and length of stay

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• _ Courteous, professional, focus and good listening skills

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• _ Weekend flexibility

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• _ Good Customer Service

Preferred Qualifications:

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• _ Bilingual

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• _ Certified in Case Management, UM, Quality, Risk or MCG

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• _ Home Care experience

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• _ Telehealth experience

Special Notes : Resume/CV should be included with the online application.

Posting Overview : This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.

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• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.

• All Hospital positions maybe subject to changes in pass days and shifts as necessary.

• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.

• This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services

• • Complete electronic reference check with a minimum of three (3) professional references.

• Successfully complete a 4 panel drug screen

• • Meet Regulatory Requirements for pre employment screenings.

• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

* The hiring department will be responsible for any fee incurred for examination .

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Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

If you need a disability-related accommodation, please call the University Office of Equity and Access at View phone number on click.appcast.io.

In accordance with the Title II Crime Awareness and Security Act a copy of our crime statistics can be viewed here .

Visit our WHY WORK HERE page to learn about the total rewards we offer.

Stony Brook University Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.

Anticipated Pay Range:

The salary range (or hiring range) for this position is $88,000 - $125,466 Base

The above salary range represents SBUH’s good faith and reasonable estimate of the range of possible compensation at the time of posting. The specific salary offer will be based on the candidate’s validated years of comparable experience. Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired.

Some positions offer annual supplemental pay such as:

• Location pay for UUP full-time positions ($3400)

• Inconvenience pay/supplemental shift differential. ($575)

Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave, health plans, and a state pension that add to your bottom line.

Job Number: 2502561

Official Job Title: : TH Staff Associate

Job Field : Professional Clinical

Primary Location : US-NY-Stony Brook

Department/Hiring Area: : Managed Care

Schedule : Full-time

Shift : Day Shift Shift Hours: : 8:30am - 5:00pm Pass Days: : Sat, Sun

Posting Start Date : May 6, 2026

Posting End Date : Aug 4, 2026, 11:59:00 PM

Salary: : $88,000 - $125,466 Base

Salary Grade: : SL4

SBU Area: : Stony Brook University Hospital

Req ID: 2502561