Rehabilitation Medicine Case Manager

SUNY Downstate Health Sciences University; New York (NY); On-site; USD 90,000 - 115,000; Full time

Job summary

SUNY Downstate Health Sciences University seeks a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Rehabilitation Case Manager to lead clinical reviews, discharge planning and care coordination within the Orthopaedic Surgery & Rehabilitation Medicine teams in New York. This role requires an active NY RN license and prior case management in acute or rehab settings.

You will collaborate with social workers, physicians and payers to ensure medical necessity, appropriate

Qualifications

• Bachelor of Science in Nursing and NYS RN licensure required.
• Minimum 2+ years as a case manager in acute care or rehab hospital settings.
• Proficiency in Microsoft Word, Excel and PowerPoint.
• Strong interpersonal, communication, administrative and organizational skills.
• Equivalent combination of experience, education and training acceptable.

Responsibilities

• Review patient records to justify medical necessity for IRF admission per MCGs.
• Collaborate with social workers, case managers and physicians for discharge planning.
• Validate admission/continuing stay criteria with payers and physicians.
• Complete clinical reviews and forward to MCOs; assess progression toward outcomes.
• Develop and evaluate discharge plans with multidisciplinary team; initiate LOS-based plans.
• Intervene when determinations are misaligned with clinical information or criteria.
• Coordinate with care teams and patients to address reimbursement issues and discharge choices.
• Participate in IRF huddles, rehab meetings and rounds; document and report progress.
• Facilitate peer-to-peer reviews and assist in QAPI and optimization initiatives.

Skills

New York State Registered Nurse LicEns

Case management experience

Microsoft Word

Excel

PowerPoint

Interpersonal skills

Administrative skills

Organizational skills

Education

Bachelor of Science Degree in Nursing

Graduate Degree in a healthcare related discipline

Case Management Certification

Tools

Careport

Allscripts EHR

Job description

Job Description

The Department of Orthopaedic Surgery & Rehabilitation Medicine at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Rehabilitation Case Manager. The successful candidate will:

• Report to the Rehabilitation Medicine Division Administrator.
• Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs).
• Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate.
• Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians.
• Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes.
• Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge.
• Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation.
• Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted.
• Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan.
• Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds.
• Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module.
• Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization.
• Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate.
• Be a team player and a role model for other staff members and students.
• Model the organization's WE CARE values.
• Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description.

Job Description

The Department of Orthopaedic Surgery & Rehabilitation Medicine at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Rehabilitation Case Manager. The successful candidate will:

• Report to the Rehabilitation Medicine Division Administrator.
• Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs).
• Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate.
• Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians.
• Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes.
• Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge.
• Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation.
• Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted.
• Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan.
• Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds.
• Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module.
• Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization.
• Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate.
• Be a team player and a role model for other staff members and students.
• Model the organization's WE CARE values.
• Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description.

Qualifications

Required Qualifications

• Bachelor of Science Degree in Nursing.
• New York State Registered Nurse Licensure.
• Current Patient Review Instrument (PRI) Certification.
• 2+ years of experience as a case manager in an acute care hospital setting or rehab hospital or Inpatient Rehabilitation Facility.
• Computer proficiency in Microsoft Word, Excel, PowerPoint.
• Strong interpersonal, communication, administrative, and organizational skills.
• Or, a satisfactory equivalent combination of experience, education and training to the above.

Preferred Qualifications

• Graduate Degree in a healthcare related discipline.
• Case Management Certification.
• Experience with Orthopaedic Surgery service line.
• Competency/experience with Careport, Allscripts EHR.