Nurse Case Manager - FT Days

Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care. Non-acute care is offered through various affiliates. Description Position Summary – Discharge Planning primarily. Under the general supervision of the Director, the Nurse Case Manager role provides clinically-based case management to support the delivery of effective and efficient patient care. Manages the case from physiological and economic perspectives. Has overall accountability for utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources. Essential Duties And Responsibilities Determines medical necessity, appropriateness of admission, continuing stay and level of care using clinical information, clinical criteria, and third party information. Intervenes when determinations are not aligned with clinical information to resolve the situation. Documents information in the current electronic system (such as MIDAS). Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate. Observation cases are a priority and should be reviewed daily. Utilizes physician advisor to interface with physicians as needed. Collaborates with third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent denial where possible. Supports the effective prevention and management of denials, including providing information as part of the appeal process. Serves as the lead in obtaining financial and other resources for patients/families in need. Assesses patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a discharge plan. Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports patient choice in establishing a discharge plan. Uses clinical knowledge to assess patient progression toward anticipated outcomes and coordinates with the patient/family and health care team to intervene when progression is stalled. Addresses barriers to discharge. Provides support and counseling to patients/families adjusting to illness, catastrophic diagnoses, changes in living situations and bereavement. Documents interventions and outcomes. Completes interventions for discharges to home with self-care, home with services and short term skilled nursing facility placement. Gathers necessary referrals, discharge summaries and relevant information prior to discharge day. Consults, assesses, refers, and coordinates interventions in cases of suspected or actual child or adult abuse/neglect or other forms of domestic or sexual abuse, as applicable. Active participation in length of stay meetings, discharge planning rounds, unit daily reports, clinical practice teams and department meetings. Identifies high risk patients and creates a collaborative plan to address their needs. Assists in legal guardianship and competency determinations and handles related documentation as required. Must have strong interpersonal and communication skills. Ability to form positive, collaborative relationships with hospital staff, patients and families. Ability to negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in solving problems. Ability to work independently and prioritize multiple priorities. Basic knowledge of computers and clinical applications. Ability to problem solve proactively with sound judgment based on factual information and clinical knowledge. Language: English (spoken and written) to perform the job safely and efficiently. Minimum Requirements : at least 3 years experience in acute care. An Associate’s Degree in Nursing is required; BSN preferred. Current RN license required. Preferred Experience : Utilization Review/Management. Company: Vassar Brothers Medical Center Org Unit: 1190 Department: Care Coordination Exempt: Yes Salary Range: $40.43 - $75.10 Hourly Seniority level

Mid-Senior level Employment type

Other Job function

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