RN Case Manager - Utilization Management

2400 Montefiore St. Luke's Cornwall; United States; On-site; USD 112,000 - 127,000; Full time

Benefits offered by this job

Health benefits

403(b) retirement plan

Tuition reimbursement

Paid time off

Job summary

Montefiore St. Luke’s Cornwall is seeking an RN Case Manager Utilization Management to support physicians and care teams in delivering optimal patient care at the appropriate level of care while controlling costs.

The role requires 3 years UR/UM experience in acute care, NYS RN licensure, and certification in Case Management within 18 months; familiarity with InterQual guidelines and Epic EMR is expected.

Qualifications

• Education/Training: NLN accredited nursing program; BSN preferred.
• Experience: 3 years UR/UM Nurse or Nurse Case Manager in acute care; EPIC EMR experience.
• Licensure: NYS RN license; Case Management certification within 18 months; NYS PRI/Screen within 3 months.

Responsibilities

• Support physician and interdisciplinary team to ensure care at the appropriate level based on medical necessity.
• Manage medical necessity reviews to certify admission and continued stay; use InterQual guidelines.

Skills

UR/UM Nurse

Critical thinking

Team collaboration

Education

NLN Accredited School of Nursing

BSN preferred

Tools

EPIC EMR

Job description

City/State: Newburgh, New York

Department: Case Management

Bargaining Unit: Teamsters Local 445

Work Shift: Day Work Days: DAYS VARY

Scheduled Hours: Hours Vary Scheduled Daily Hours: Hours Vary

Pay Rate/Range: $112,480.87 - $127,155.60

Sign-On Bonus: N/A

Job Description

The RN Case Manager Utilization Management is responsible for supporting the physician and interdisciplinary team in facilitating patient care, at the appropriate level of care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The individual in this position has primary responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity. This position manages the medical necessity review process to ensure accurate and timely payment for services. This role integrates and coordinates utilization management by performing clinically based medical necessity reviews using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital. Progression of care is managed by using bench marked evidence-based criteria (i.e., InterQual).

Position Qualifications

• A. Education/Training: Graduate of NLN Accredited School of Nursing, BSN preferred. Ability to read, write, and communicate in English.
• B. Experience: 3 years of experience as a Utilization Review/Utilization Management (UR/UM) Nurse or Nurse Case Manager with primary responsibility for UR/UM in an acute care setting required. Experience with EPIC EMR. Proficiency in applying InterQual guidelines for medical necessity. Familiarity with processes of critical payers such as Aetna, UHC, MVP, BCBS. Must have experience forming positive, collaborative relationships with hospital staff, providers, patients, and families. Must demonstrate critical thinking skills to find solutions to problems, work independently, manage stress, prioritize work, and maintain calm demeanor in stressful environment.
• C. Licensure: Current New York State Licensure as a Registered Professional Nurse. Certification in Case Management required 18 months after eligibility. NYS PRI and Screen certification required within 3 months of hire/transfer.

Montefiore St. Luke's Cornwall is an equal employment opportunity employer. Montefiore St. Luke's Cornwall will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.

About Montefiore St. Luke’s Cornwall

For 150 years, Montefiore St. Luke’s Cornwall (MSLC) has been a cornerstone of high-quality healthcare in Orange County, fostering a healing environment through community collaboration, dedicated staff, and a rich history. What began as a modest three-bed hospital in 1875 has grown into a comprehensive healthcare system with two campuses and a wide range of outpatient services. MSLC is a member of the Montefiore Health System and provides care to more than 250,000 patients annually.

The organization includes a 242-bed acute care hospital, with a geographic coverage area that serves a population of 400,000 people. MSLC is proud to provide care locally, and when needed, offer seamless transitions to world-class medicine throughout the Montefiore Health System (MHS). Being part of MHS has allowed MSLC to expand our capabilities and offer cutting-edge healthcare to our community. MSLC is a Magnet designated organization, with notable recognition from Healthgrades, the American Heart Association, and various other agencies. We are accredited by The Joint Commission, which sets the standards for the delivery of quality health care. MSLC has more than 350 physicians on staff, representing dozens of medical specialties.

Montefiore St. Luke’s Cornwall strives to be the employer of choice by offering comprehensive benefit packages that are designed to meet the needs of today's workforce. We are committed to assisting employees to achieve optimal health, wellness, and financial security.

Benefits

• medical, dental, vision, and life insurance, 403(b) retirement plan, tuition reimbursement, a generous paid time off plan, as well as various other optional benefits.