Case Management Nurse

New York, NY

Posted: 02/14/2020 Job Number: 13940409

Job Description

A growing organization is looking for a Case Management Nurse to identify health care gaps/opportunities. This individual will be responsible for the development, implementation, and monitoring and evaluation of individualized care plans in accordance with evidence-based guidelines; those care plans will identify resources to close care gaps and optimize the consumer's health. The CM nurse will act as an advocate assisting consumers in navigating/mitigating the social determinants that impact the consumer's health; in that advocacy role, the CM nurse will help consumers with serious medical conditions get the care they need when they need it. The CM nurse will serve as a liaison between a consumer, their family and health care providers as appropriate.

  • Conducts prospective, concurrent and retrospective utilization review for consumers with specific outpatient service requests as well as consumers receiving inpatient, observation or SNF services
  • Works with physician reviewers, Medical Directors and Intake Coordinators to perform first-level reviews to pre-certify elective services, procedures and tests for consumers utilizing established policies and protocols, benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination
  • Knowledge of consumers' benefits
  • Follows the Case Management Standards of Practice, Ethical standards, department policies and procedures, and compliance regulations for reviewing and managing cases
  • Obtains clinical, functional and psychosocial information from the medical records
  • Refers cases for medical review according to policy and procedure
  • Documents clinical, functional, psychosocial information in the case management software system
  • Collaborates with attending physicians and health care professionals
  • Issues regulatory and other letters
  • Clarifies policies/procedures and consumer benefits as needed
  • Strictly observes policies regarding confidentiality of consumer information and documentation standards
  • Requests and obtains relevant clinical information from medical care providers
  • Conducts clinical reviews of proposed services against appropriate criteria/guidelines
  • Refers all cases that do not meet medical necessity, benefit eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review of the referred case
  • Reviews physician reviewers' determinations for appropriateness and completeness
  • Communicates determinations to providers and consumers telephonically and in writing, adhering to corporate/department policy and regulatory guidelines
  • Works with social workers to access community resources that will facilitate optimizing consumer health
  • Works with facility case management department or specifically assigned staff to develop appropriate discharge plans; implements and continually reassesses care plans and discharge plans for consumers
  • Works collaboratively with the rest of the team when additional resources are needed to time effectively manage the workload

  • Education: Graduate from an accredited school of nursing. Bachelor's degree required. Bachelor's degree in nursing preferred
  • License: An active and unrestricted license as a registered nurse (RN) in New York
  • Certification: Certified in Case Management
  • Experience: A minimum of three years clinical experience as a Registered Nurse required. Two years of experience as a case management nurse in a payer or facility setting is also required.
  • Demonstrates commitment
  • Ability to follow the 'logical' management of a consumer's care throughout the continuum of care
  • Grasps complexities and perceives relationships among problems or issues
  • Proactive in developing solutions to challenging clinical situations
  • Seeks input from others
  • Is willing and able to adjust to multiple demands, shifting priorities, ambiguity and rapid change
  • Shows resilience in the face of constraints, frustrations or adversity
  • Excellent written and verbal communication skills
  • Excellent organizational skills
  • Accurate and timely data entry

Meet Your Recruiter

Jessica Swanson

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