RN Case Manager: Care Transition & Utilization Lead

SUNY Downstate Health Sciences University; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review Quality Assurance Senior Coordinator / RN Case Manager in New York. The role focuses on hospital case management, utilization review, and discharge planning to ensure smooth transitions of care.

The position requires NY RN licensure, a nursing degree, and PRI certification, with preferred graduate and case management certifications.

Qualifications

• Current New York State Registered Nurse Licensure.
• Bachelor's Degree in Nursing required.
• PRI Certification required.

Responsibilities

• Provide hospital case management, utilization review and discharge planning to ensure patient progresses through continuum of care.
• Utilize Milliman Care Guidelines (MCG) to justify level of care, medical necessity, LOS and intensity for inpatient admissions.
• Perform initial clinical reviews and continued care reviews for hospitalized patients to determine medical necessity.
• Conduct initial clinical assessment within 24 to 48 hours and perform reassessments as needed based on patient acuity.
• Promote interdisciplinary collaboration and provide resources to the team on medical necessity and documentation requirements.
• Collaborate with Social Work, Nursing and other teams on treatment plans and transition of care post-hospitalization.
• Communicate with patient/family and consider cultural factors affecting stay and discharge planning.

Skills

RN License (NY)

Discharge planning

Utilization review

Care coordination

Education

Bachelor's Degree in Nursing

PRI Certification

Graduate Degree in Healthcare

Case Management Certification

Job description

SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review Quality Assurance Senior Coordinator / RN Case Manager in New York. The role focuses on hospital case management, utilization review, and discharge planning to ensure smooth transitions of care.

The position requires NY RN licensure, a nursing degree, and PRI certification, with preferred graduate and case management certifications.