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JOB DESCRIPTION

The Case Manager is responsible for all aspects of case management/ utilization review for an assigned group of inpatients, ED patients and Observation ( RETU) patients to determine the correct Level of care ( LOC), appropriateness of the admission and continued stay, assist in the development of the plan of care; ensure that the plan is implemented in a timely basis and identify the expected length of stay (ELOS). The case manager works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed to develop a plan of care which includes discharge planning, resource management, health education, and the provision of information as it relates to care management and the transition of care. The Case Manager actively participates in specific clinical initiatives focused on LOC, reducing the length of stay (LOS), improved efficiency and quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services. Responsible For A group of inpatients to determine the appropriateness of the admission and continued stay, assist in the development of the plan of care, ensure that the plan is implemented in a timely basis, and identify the expected length of stay (ELOS) and problem solves care transitions accordingly within the interdisciplinary health care team.

RESPONSIBILITIES

1. Principal Duties and Responsibilities Principle Duties and responsibilities include, but are not limited to: • Review and advice for appropriate level of care using criteria sets (refer to designated site software), cases referred or who have Observation diagnosis, or other high risk diagnosis as well as readmissions. • Review all patients in RETU to insure they meet Observation criteria, assist with discharge or admit to next LOC with-in unit specified timeframes. • Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization. • Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay. • Oversee clinical throughput of patient, ensuring medical treatment plan, e.g., timely tests, consults. • Collaborates with Physicians and other clinicians to expedite diagnostic testing, treatment and consultations. • Documents all clinical reviews in using designated site software program. • Supports the mission, vision, philosophy and goals of the Medical Center. • Promotes an environment that is sensitive to cultural diversity and is open and responsive to the diverse backgrounds and experience of others. • Liaison with Physician Advisor.

2. Case Management: • Assessment of the patient’s clinical, psychosocial, and functional status in collaboration with the interdisciplinary team. • Identification and documentation of variances affecting the LOS and the discharge planning process. • Conducts follow-up of any delays in treatment or reporting of results. • Planning/developing specific goals with the physician, interdisciplinary team, and the patient and/or family. • Implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care. • Determine ALC status and track avoidable days. • Documentation of outcomes achieved and identified internal and external barriers. • Identifies reasons for readmissions and collaborates with interdisciplinary team on strategies to reduce readmission rate. • Appropriately identifies and refers cases to the physician advisor to support timely progression of patients along the continuum of care and (appropriate) discharge planning. • Interacts with patient/family to discuss plan of care and coordination of services based on clinical needs and available resources.

3. Utilization Review: • Maintains a working knowledge of the UR requirements of each payor within the patient population • Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion. • Provides clinical information requested by the managed care companies in accordance with contractual agreements. • Works collaboratively with physicians and managed care companies on concurrent denial appeals • Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor Medical Director as required. • Performs additional duties as assigned.

4. Discharge Planning • Responsible for assessment, communication and monitoring of discharge planning process in collaboration with the clinical nurse initiates the discharge planning process on admission. • In collaboration with Social worker, obtains authorizations from managed care companies for post-discharge services. • Assesses for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement. • Assist in having appropriate staff complete discharge forms in a timely manner. • Coordinates the Discharge Appeal process. • Liaison with financial department for current insurance coverage. • Collaborates and participates in concurrent denial and appeals process with all members of the interdisciplinary team.

5. Communication and Collaborative Relationships • Develops and maintains effective working relationships with interdisciplinary team and with managed care/community organizations. • Interfaces with other departments within the Hospital effectively. • Demonstrates a professional, courteous and respectful attitude in dealing with patients/families/care givers and members of the health care team

6. Educational/Professional Development • Participates in the development of unit based staff. • Meets regulatory, licensure and annual health assessment requirements. • Identifies own learning strengths and needs through ongoing self assessment • Utilizes learning resources. • Seeks educational opportunities to maintain and enhance competence within current advances in health care delivery and case management • Provides presentations and educational offerings as needed. • Participates in special projects and committees. • Attends relevant workshops, conferences and seminars • Demonstrates membership in professional and related organizations. • Demonstrates competence in case management and required information technology and systems.

QUALIFICATIONS

Collective bargaining unit: NYSNA-SLW

ABOUT US

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

“About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.”

EOE Minorities/Women/Disabled/Veterans

Requisition ID : 3003608