Care Manager - Readmission Specialist

Position Summary Care Manager – Readmission Specialist. Must have both hospital and transitional care experience. Identifies hospitalized patients who may be at a high risk for readmission. 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 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. Advocate on the patient’s behalf to help ensure they receive appropriate care. Work to identify any social determinants 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 patient’s 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. Required Qualifications Bachelor’s degree with 3‑5 years CM experience. NY RN License. Acute hospital experience. Transitional experience. Experience with post‑acute care coordination, including acute rehab/skilled nursing. Computer proficient in Electronic Medical Record applications. Demonstrate knowledge of discharge planning and length of stay. Courteous, professional, focused and good listening skills. Weekend flexibility. Good Customer Service. Preferred Qualifications Bilingual. Certified in Case Management, UM, Quality, Risk or MCG. Home Care experience. Telehealth experience. Special Notes Resume/CV should be included with the online application. Anticipated Pay Range $88,000 – $125,466 Base. Official Job Title TH Staff Associate Job Field Professional Clinical Primary Location US‑NY‑Stony Brook Department/Hiring Area Managed Care Schedule Full‑time EEO Statement 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. #J-18808-Ljbffr Stony Brook Medicine