White Plains Hospital Center - White Plains, NY

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Category: Nursing
Schedule: Full Time
Shift: Day Shift
Hours: 9-5 M-F
Job Details: Bachelor's Degree
Professional License Required

Position Summary:
The Care Manager (CM) coordinates the clinical and financial plan for assigned patients. He/She will perform overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. He/She will also work with multi-disciplinary team in resource management, discharge planning and transitions of care to facilitate the discharge plan. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians and insurance carriers. Ensures continuity in the delivery of services across departments. Collaborates with the patients physicians re ongoing documentation, to ensure insurance approval and assists the physician in the peer to peer appeal process.

Job Responsibilities:
See below. Performs other duties as assigned.

Patient Care / Patient Education

Assumes an active role in the planning and implementation ofeducational needsof assigned patients with direct care team

Coordinates assigned patientsclinical plan, discharge plan of care, and targeted LOSwith appropriate care team and communicates plan to patient/family

Communicates post-acute services andpayer requirementsto patient/family as needed according to current understanding of care needs

Discharge Planning

Initiates discharge planning on admission and ensures documentation is completed and updated regularly

Identifies the estimated discharge date upon admission and documents forLOS management based on Milliman guidelines.

Collaborates with patients, caregivers, healthcare agencies and payers to plan and implement a safe discharge plan.

Identifies barriers to discharge and works with the multi-disciplinary team to expedite care, monitor length of stay, and facilitate discharge

Addresses complex clinical and social situations efficiently to avoid unnecessary delays in discharge. Documents variances( delays in dc ) in the eDischarge system( avoidable days)

Re-evaluates/revises discharge plan as patients clinical condition warrants in collaboration with the SW.

Develops alternative discharge plan(s) in anticipation of changes in patients post acute needs, to prevent delays in discharge.

Coordinates post-acute service referral needs through theresource center

Uses Milliman to determine appropriate level of care (skilled, rehab, etc) and obtains needed payer authorizations for post acute care.

Obtains thesupportof the social worker for complex social issues, behavioral problems, home and family issues, complex discharges and placements.

Care Facilitation

Develops, manages, and drivesclinical plan of carewith physician and assigned unit or service multi-disciplinary care team

Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensuretimely patient management and discharge process.

Coordinates patient careacross unitsto reduce fragmentation of care and addresses/ resolves system issues impeding progress, including, but not limited to, pending orders or procedures, waiting on test results, needing MD discharge order and discharge instructions.

Leads weekly complex care roundscases reviews and runsdaily interdisciplinary roundswith assigned care team to manage progress toward expedited discharge plan.

Expedites throughput of the complex patient to meet overallLOS, quality and resource utilizationgoals

Identifies &refers patients for social workerintervention, as well as transitions of care follow up at home.

Utilization Management

Performs clinical review on admission, and/or continued stay- every 3-5 days, to determine appropriate level of care (Inpt, Obs, etc)and questions MD placement of patient onto unit when LOC criteria not meet

Follows payer specific requirements to obtain and document authorizations in Midas

Reviews medical record daily to ensure patient continues to meet level of care requirements, and discusses the outliers with the physician advisor as needed.

Ensures that medical record documentation supports level of care

Works with Physicians and Clinical Documentation Specialists, to obtain documentation to support current level of care

Updates level of care as needed

Expedites discharge planning for patients who no longer require hospital services

Communicates with physicians and nursing regarding resourceutilization, LOS, level of care, and post acute care placement

Takes leadership role in concurrent denial process and assists the physician in his peer to peer review process, to get the case approved on a one to one basis.

Documentsavoidable daysandcommunicates, if needed regarding any denials for assigned patients into eDischarge.


Acts as resource to clinical and finance teams for level of care, insurance coverage issues, specific payer and government policies and post-acute services coverage and availability

Promotes patient safety

SupportsCOREmeasures information for JC requirements upon discharge.

Education, Training, Licensure and Experience Requirements

BSN or related Bachelor's degree preferred

5 years clinical ED, critical care or med/surg experience required

Previous case management experience preferred

Knowledge of healthcare financial and payer issues preferred

Knowledge of state, local, and federal programs preferred

Use of Milliman/InterQual criteria preferred

  • Registered Nurse (R.N) in NYS required
  • PRN/Screen certification required.
  • C.C.M. (Certified Case Manager) certification helpful or attendance in a CM educational course
in a uni - 18 months ago - save job
About this company
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White Plains Hospital is a voluntary, not-for-profit health care organization with the primary mission of offering high quality, acute...