Senior Rehab Case Manager & Utilization Review Lead

SUNY Downstate Health Sciences University

New York (NY)

On-site

USD 90,000 - 115,000

Full time

14 days+

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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.