RN Case Manager

Overview

St. John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.

St. John’s has been an integral part of the community since the 1890's and its’ commitment to provide the community with the most advanced medical services available continues to be the hospitals’ vision, mission and value. St. John's Riverside Hospital built itself around an early foundation of nursing and community service. In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul. St. John’s dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.

St. John’s Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. John's Riverside Hospital to their care.

St. John’s Riverside Hospital  is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.

Personalized care together with advanced technology is what it means to be Community Strong

Responsibilities

Assists in meeting the psychosocial needs of patients and families, through assessment ofinpatients based on assignment. Patients are screened for continuing care needs, including emotional support, community resource needs, home care, in patient care and health insurance issues. The Case Manager will assess patients and conduct medical insurance reviews for them. Educates, coordinates, and collaborates with nurses, physicians, Continuing Care Coordinators and interdisciplinary members of the Healthcare team, to assure an ongoing comprehensive discharge plan.

Ensures appropriate use of resources within an appropriate length of stay. Collaborates with the multidisciplinary team on the patient’s treatment plan.

Reviews admissions and continued stays in accordance with established criteria. Conducts all adjunct procedures such as referrals to the Medical Director, keeps statistics, performs insurance reviews, and identifies quality of care issue.

ESSENTIAL FUNCTIONS/RESPONSIBILITIES

Under the immediate supervision of the Director of Case Management, and Vice President for Medical Affairs, a successful employee must demonstrate competency in the following areas:

Utilizes electronic Utilization Management platform for assigned units/patient’s and assesses the patient’s medical, social, financial, and psychological status within three days of patient’s admission. A Case Manager is assigned to assess all patients in the Intensive Care Unit and manage their discharge plan until the patient transfers to another level of care. The CM, through assessment and reassessment, will manage the discharge planning needs of the patients assigned to them and review cases for quality of care and utilization management issues. CM will consult CCC team member for the discharge planning needs of patients who are on palliative care, patient’s that are substance abusers, homeless and uninsured, patients, victims of domestic violence, elder abuse, and child abuse, patients who need referrals for inpatient and outpatient terminal care, inpatient, outpatient psychiatric care, Subabcute and Acute Rehab placements, Home Visiting Nurse services and patients living in assisted living facilities, group homes and adult homes. The dedicated CCC will be consulted for patients newly diagnosed with cancer for community support services. The CCC will be consulted for patients who require guardianship and the CCC will follow through on their discharge plan. A Case Manager is assigned to the Emergency Department and will consult the CCC for any social needs.

Counsels the patient and significant others in the admitting criteria and referral process to the below services. CM will follow through on these referrals to ensure a safe discharge plan. Case Manager is responsible for the completion of PRI’s and Screen’s, to issue the Important Message from Medicare during regular department hours as needed and to follow through with IPRO if the patient requests an appeal. CM will refer cases to the CCC and assist as needed such as:

Visiting Nurse Services Inpatient Skilled Nursing Care and Acute RehabilitationLong Term Home CarePersonal Care Services Home Infusion Therapy and Wound CareOrdering of Durable Medical Equipment other community resources as needed

Counsel’s patients and their families in relation to anxieties and stress precipitated by illness and hospitalization, difficulty in coping with residual disability, fears related to helplessness, loss of capabilities, and death.

Collaborates with community professionals in order to develop a discharge plan and continuity of care. Works with CCC and obtains community resources in order to develop discharge plan for the patient. Maintains a resource file and follows referral procedure to extended services available for patients, to meet their needs. Utilizes interview skills to determine:Patient’s discharge planning goalsFamily’s discharge planning goalsNeed for institutional and/or specialized careMulti-disciplinary teams goals for patient including (primary care physician, primary care nurse, continuing care coordinator, physical therapist, visiting nurse, speech pathologist, dietician)Incorporates a,b,c,d, into an appropriate discharge plan for the patient

Assists in obtaining MD order and insurance authorization for the patients post hospital needs; i.e.: Certified Home Health Agency Inpatient Skilled Nursing Care and Acute RehabilitationInfusion therapy, wound care Medical supplies and equipmentTransportation

Communicates to the patient their right to seek services outside of the authorization of their insurance carrier as long as they will assume responsibility for payment of these services.

Assists family members and significant others in arranging for burial of a patient which may include obtaining community resources, contact with clergy and other family members.

CM is assigned to do pre assessment, initial discharge planning and overview of community and residential services for patients admitted through Same Day Surgery preparing for total joint replacement. CM is also assigned to the Ambulatory Services Unit for discharge planning needs.

Collaborates closely with hospital benefits area in identifying change of benefit status or lack of insurance.

Participates in the performance improvement activities of the department by monitoring length of stay and denials.

Refers cases regarding quality of care and utilization issues to appropriate administrator i.e. AVP for Performance Improvement, VP for Medical Affairs, ICP or Assistant Director of Case Management.

Performs medical insurance reviews concurrently and retrospectively as assigned. Collaborates with Physician and Nursing to provide medical necessity criteria to the payor. Assists in the appeals process by documenting crucial areas with in the stay that could have been improved or were necessary to justify the stay.

Assumes responsibilities of CCC as needed when CCC staff is limited.

.Assumes other responsibilities when assigned.

Qualifications

Must be a NYS licensed RN, Bachelor’s preferred, with at least 3 years discharge planning or Case Management experience preferred.

New York State PRI assessment certification desirable.

Able to read, write, speak, and understand the English language. Ability to communicate Spanish or community dominant language is an asset.

Effective professional rapport with physicians, patient, family/visitor, peers and supervisors. Sensitivity and Compassion.Knowledge of the services of the community, health, welfare, and social agencies.

Demonstrates flexibility and creativity. Must be able to function well under pressure. Must have good leadership ability and good judgment. Must have good mental and physical health.

Must be educated in the use of the particulate respirator (mask).