Case Manager Rn Continuum of Care

Hospital for Special Surgery; New York (NY); On-site; USD 146,000 - 162,000; Full time

Job summary

Hospital for Special Surgery is seeking a Registered Nurse with case management experience to oversee transitional care for high‑risk orthopedic patients. You will coordinate discharge planning, communicate with families, and document care plans in the EMR, ensuring a smooth transition from hospital to home or rehab.

The role requires a NYS RN license, at least 2 years of hospital nursing experience, and a focus on evidence-based discharge planning.

Qualifications

• Bachelor’s degree in nursing required.
• New York State professional license/registration required.
• CCM certification preferred.

Responsibilities

• Provides transitional care support to high‑risk orthopedic patients after discharge.
• Applies case management process: assessment, planning, implementation, coordination, monitoring and evaluation.
• Screens patients within 24 hours of admission for discharge planning needs and develops discharge plans.
• Documents plan of care and discharge updates in the EMR within defined timelines.
• Educates patients and families to enable informed decisions about treatment and discharge.

Skills

Communication

Customer service

Regulatory knowledge

Discharge planning

EMR documentation

Education

Bachelor’s in nursing

New York State license/registration

CCM preferred

Job description

How you move is why we’re here.
Now more than ever.

Get back to what you need and love to do.
The possibilities are endless…

Now more than ever, our guiding principles are helping us in our search for exceptional talent - candidates who align with our unique workplace culture and who want to maximizethe abundant opportunities for growth and success.
HSS is consistently among the top-ranked hospitals for orthopedics and rheumatology by U.S. News & World Report. As a recipient of the Magnet Award for Nursing Excellence, HSS was the first hospital in New York City to receive the distinguished designation. Whether you are early in your career or an expert in your field, you will find HSS an innovative, supportive and inclusive environment.

Working with colleagues who love what they do and are deeply committed to our Mission, you too can be part of our transformation across the enterprise.

Emp Status

Regular Full time

Work Shift

Day (United States of America)

Compensation Range

The base pay scale for this position is $145,617.13 - $162,229.63. In addition, this position will be eligible for additional benefits consistent with the role. The salary of the finalist selected for this role will be determined based on various factors, including but not limited to: scope of role, level of experience, education, accomplishments, internal equity, budget, and subject to Fair Market Value evaluation. The hiring range listed is a good faith determination of potential compensation at the time of this job advertisement and may be modified in the future.

What you will be doing

Job Qualifications

EDUCATION - Required

• Bachelor’s in nursing

CERTIFICATION – Required

• New York State professional license and/or registration, New York
• Current New York State professional RN license and/or registration

CERTIFICATION – Preferred

• CCM preferred
• PRI/screen certification

EXPERIENCE – Required

• 2 years of Nursing in a hospital setting

EXPERIENCE – Preferred

• Orthopedic nursing
• Two years experience in case management with discharge planning or equivalent in acute or home care clinical setting.

SKILLS - Required

• Excellent verbal and written communication skills.
• Strong customer service orientation.
• Knowledge of regulatory agency standards. Strong problem-solving skills. Ability to manage multiple tasks and projects independently.
• Ability to assess clinical and discharge needs of hospital patients

SKILLS – Preferred

• Ability to assess clinical and discharge needs of orthopedic surgical patients. Knowledge of Milliman (MCG) criteria.

POSITION & UNIT ACCOUNTABILITIES – AKA Competencies

• Provides transitional care support to high-risk orthopedic patients following hospital discharge through structured telephonic outreach and EMR-based communication, assessing recovery, reinforcing the discharge plan, and supporting a safe transition to home and the next phase of care.
• Demonstrates knowledge and competency in care management concepts by applying the case management process to an assigned group of patients. This includes assessment, planning, implementation, coordination, monitoring and evaluation of the plan of care.
• Screens patients within 24 hours of admission for discharge planning needs and subsequently develops, implements and reviews discharge plan to meet patient’s specific continuing care needs.
• Assesses patient’s current functional status as compared to pre-hospital status and collaborates with patient/family and interdisciplinary team to develop an appropriate discharge plan to meet the patient’s continued rehabilitation needs; i.e. home care, DME, acute/sub-acute rehab.
• Provides timely documentation in the EMR (within 24 hours of admission, upon change of condition or plan and every 72 hours until discharge) detailing the patient’s plan of care, discharge plan, changes/status of the discharge plan and progress patient has made toward desired outcomes.
• Plans and carries out interventions with active participation of patient, family and healthcare team; educates patients and/or families to assist them in making informed decisions regarding treatment and discharge.
• Provides patients with a choice of post-acute providers and documents appropriately in the EMR
• Participates in daily interdisciplinary rounds to facilitate plan of care, collaborates with healthcare team, and seeks to eliminate barriers to efficient delivery of care and timely discharge in order to facilitate patient throughput.
• Ensures that all elements critical to the plan of care and discharge plan have been communicated to the patient and family necessary.
• Assess patient’s continuing care needs and monitors response to treatment plan through collaboration with patient and healthcare team. Ensuring the discharge plan is updated to meet the patient’s changing needs.
• Ensures that prior to discharge, the patient’s final discharge disposition, discharge plan and next level provider are accurate, updated and congruent
• Evaluates patients readmitted within 31 days to identify potential causative factors, integrates findings into plan of care and possible need for alternate discharge plan.
• Acts as patient advocate to ensure that patients receive appropriate care under benefit entitlements. Identifies financial constraints affecting access to care and utilizes community resources/funding to assist in meeting patient’s needs.
• As applicable, incorporates identified process improvements into daily practice (QI activities and Press Ganey surveys).
• Maintains and develops competence through required in-service and continuing educational programs.

Non-Discrimination Policy

Hospital for Special Surgery is committed to providing high quality care and skilled, compassionate, reliable service to our community in a safe and healing environment. Consistent with this commitment, Hospital for Special Surgery provides care, admits, and treats patients and provides all services without regard to age, race, color, creed, ethnicity, religion, national origin, culture, language, physical or mental disability, socioeconomic status, veteran or military status, marital status, sex, sexual orientation, gender identity or expression, or any other basis prohibited by federal, state, or local law or by accreditation standards.