Be an Early Applicant
The Role
Provides hospital case management, utilization review, clinical assessments, discharge planning, and transition-of-care coordination. Reviews medical necessity using MCG criteria, documents patient progress and delays in CarePort, completes New York State PRI assessments, coordinates skilled nursing facility authorizations, addresses readmissions, supports regulatory documentation, and facilitates communication among patients, families, physicians, social workers, nursing teams, and managed care organizations.
Summary Generated by Built In
The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review Quality Assurance Senior Coordinator / RN Case Manager. The successful candidate will:
- Provide hospital case management, utilization review and discharge planning to ensure that the patient progresses through the continuum of care and discharged through a well-coordinated transition of care plan.
- Utilize standard review criteria specifically the Milliman Care Guidelines (MCG) to justify level of care, medical necessity, expected length of stay and intensity for inpatient admissions.
- Perform initial clinical reviews and continued care reviews for hospitalized patients using standardized care guidelines to determine medical necessity for inpatient admissions or for placement in other appropriate levels of care.
- Conduct an initial clinical assessment within 24 to 48 hours. Perform reassessments as necessary based on patient acuity.
- Promote interdisciplinary collaboration by providing resources to the interdisciplinary team when appropriate on issues of medical necessity and clinical documentation requirements.
- Collaborate with Departments of Social Work, Nursing and other medical teams to discuss patient treatment plan and transition of care post-hospitalization.
- Communicate with patient/family members appropriately and be cognizant of cultural facts that can affect hospital stay and discharge planning.
- Document delays or variances from expected length of stay in CarePort (Care Management Platform).
- Identify patients who were readmitted within 30-days. Assess for actual/potential risks then confer concerns to medical team and appropriate social worker. Document interaction in patients' medical record.
- Complete the Patient Review Instrument (PRI) as mandated by New York State.
- Transmit Patient Review Instrument (PRI) to facilities and MCO in order to secure authorizations for transfer to SNF and SAR.
- Facilitate concurrent request for reconsideration of potential denials. Coordinate peer interactions between SUNY University Hospital physicians and the Managed Care Organization physicians to prevent denial of reimbursements.
- Ensure patients are placed in the proper level of care by communication with the appropriate physicians
- Ensure the appropriate documents that meets regulatory requirements are in the medical record e.g. IMM forms (signed), observation notices (signed).
Required Qualifications
- Current New York State Registered Nurse Licensure.
- Bachelor's Degree in Nursing.
- PRI Certification.
Preferred Qualifications
- Graduate Degree in Healthcare preferred.
- Case Management Certification preferred.
Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.
About the Team Equal Employment Opportunity
SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws.
Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply.
If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at [email protected].
Skills Required
- Current New York State Registered Nurse licensure
- Bachelor's degree in Nursing
- PRI Certification
- Graduate degree in Healthcare
- Case Management Certification
Am I A Good Fit?
Get Personalized Job Insights.
Our AI-powered fit analysis compares your resume with a job listing so you know if your skills & experience align.
Success! Refresh the page to see how your skills align with this role.
The Company
What We Do
SUNY Downstate Health Sciences University is Brooklyn’s only academic medical center and part of the State University of New York. Through five schools and University Hospital at Downstate, it educates physicians, nurses, scientists, public-health leaders, and allied health professionals; advances biomedical, healthcare, and public-health research; and delivers patient-centered care while promoting health equity for New York’s diverse communities across the borough.
