Nurse, Care Management - Full-Time, Days *3 Years of Clinical RN Acute Care Experience REQUIRED*

Nurse, Care Management - Full-Time, Days

NYU Langone HospitalLong Island is a 591-bed university-affiliated medical center, which offers sophisticated diagnostic and therapeutic care in virtually every specialty and subspecialty of medicine and surgery. We are a major regional healthcare resource with a deep commitment to medical education and research, offering a full complement of inpatient and outpatient services. At NYU Langone Health, equity and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive. We embrace inclusion and individual skills, ideas, and knowledge.

Position Summary: We have an exciting opportunity to join our team as a Nurse, Care Management - Full-Time, Days. In this role, the successful candidate coordinates and procures services necessary to meet the post-acute care needs of patients identified as requiring such services. Ensures a timely and smooth transition to the most appropriate post-acute care setting. Works collaboratively with interdisciplinary patient care staff both internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care. Ensures maximization of provider reimbursement of patient days through timely and accurate insurance reviews.

Job Responsibilities:

• Performs other duties as assigned
• Performs an initial utilization review of patients for appropriateness of setting using industry standard utilization clinical criteria including, but not limited to InterQual, Milliman Care Guidelines (MCG), etc. Collaborates with the Attending of record and the Physician Advisor as indicated for review of any patient not meeting criteria for level of care ordered. Performs continued stay and extended stay reviews when there is a change to a higher level of acuity, authorized days expire, required by the insurance payer contractual agreement, stay is denied or reduced to a lower level of care.
• Provides patient clinical reviews to payer in a timely and efficient manner to obtain certification of the patient days and secure reimbursement. Confers with Attending Physician, Physician Advisor, and multidisciplinary team as needed to mediate concurrent denials.
• Screens all inpatients utilizing case management departmental screening criteria for potential post acute care needs. Perform an assessment for discharge needs for all patients that meet screening criteria, are referred by care team or are requested by patient/designee. Develops a discharge plan in collaboration with the patient/designee and care team incorporating patient preferences. Implement the discharge plan with referrals, including necessary medical information, to appropriate post acute care services. Reassessment of this process will be done with ongoing review of all readmissions to ensure that the plan was responsive to the discharge needs.
• Completes all necessary documentation as per departmental policy and procedure utilizing Allscripts. Completes Patient Review Instrument (PRI) accurately and in a timely manner.
• Identifies and reports risk and quality issues to appropriate department. Tracks avoidable days in Allscripts to identify opportunities for improvement.
• Provides patients with all necessary notices in accordance with requirements for CMS conditions of participation and insurance payer contracts. Issue Important Message (IM), Discharge Notice, Advanced Beneficary Notice (ABN), Detailed Notice of non-coverage, Preadmission/Admission Notice of non-coverage and Hospital Issuance of non-coverage (HINN) as appropriate and in accordance with hospital policy and procedure. Process Medicare Code 44 as appropriate in accordance with policy. Ensure patientdesignee is provided with eplanation of billing status when a Code 44 or observation is ordered.
• Participates in patient care unit interdisciplinary meetings to assess patients' current and projected clinical status, plan of care, discharge plan and expected discharge date. Facilitates communication among the interdisciplinary health care team members. Coordinates patient care conferences among appropriate team members and patient/designee to discuss identify barriers, concerns, resolve conflicts and communicate choices in the plan of care. Participates in in-service activities and continuing education programs as scheduled.

Minimum Qualifications: To qualify you must have a Bachelor's degree in Nursing required for employees hired after 9/1/2020 (those who were hired prior to 9/1/2020 are grandfathered). Current and valid New York State Registered Nurse License. BLS certification (Issued by the American Heart Association-AHA). 3 - 5 years Clinical acute care. Excellent communication (both oral and written), interpersonal, organizational skills. Knowledge of clinical standards of practice for multiple patient populations. Computer skills. Required Licenses: Registered Nurse License-NYS

Preferred Qualifications: Bachelor's Degree Nursing. New York State Department of Health Patient Review Instrument (PRI) Assessor. 3 - 5 years Discharge planning and/or utilization management. Knowledge of post-acute care referral process for the procurement of patient services. Knowledge of Hospital reimbursement process, insurance denials and appeals.