Case Manager Family Health Centers Brooklyn- RN required
Company: NYU Langone Health
Posted on: May 16, 2022
NYU Langone Hospital - Brooklyn is a full-service teaching
hospital and Level I trauma center located in Sunset Park,
Brooklyn. The hospital is central to a comprehensive network of
affiliated ambulatory and outpatient practices, and serves as NYU
Langone Healths anchor for healthcare access, growth, and delivery
in the entire borough. Learn more about, and interact with us
on,,,,, -and -.Position Summary:We have an exciting opportunity to
join our team as a Case Manager-Family Health Centers Brooklyn.
-This position is responsible for care coordination with emphasis
on services incurred outside the inpatient hospital setting. Care
coordination includes assessing healthcare needs, identifying
problems and opportunities for improvement, implementing
intervention, managing the patient care transition process,
assisting patients throughout care episodes, coordinating and
facilitating care for patients with complex and chronic conditions,
providing disease education, and promoting evidence based
healthcare services. The individual in this position works as part
of an interdisciplinary team to ensure high quality outcomes for
patients/families struggling with chronic disease management.Job
- Provide care coordination for patients including patient
navigation, chronic disease management/education and
interdisciplinary collaboration while complying with department and
agency policies and procedures and other contractual
- Monitor remote patient monitoring tools and notify
interdisciplinary team when follow-up is required to address out of
- Work with patient and care team to conduct assessments that
result in a comprehensive care plan that contains goals prioritized
by the patient and/or provider. Track overtime goal outcomes,
interventions, and continue to reassess the patients needs as
appropriate. Establish appropriate timeframe for frequency of
follow-up activities and provide closure and referral services as
patient move through and complete programming.
- Engage patients in taking a proactive role for managing their
health, medications, treatment and rehabilitation needs, and
follow-up appointments and refer patients to the appropriate
community based, health plan or other programs.
- Interact with relevant providers stakeholders and collaborate
with relevant staff to support regular interactions with
- Follow evidence based guidelines and contact standards to
facilitate closure of gaps in care and encourage and use of in
- Use the Epic electronic medical record to conduct care
coordination activities and comply with associated policies and
procedures including those for work flow and consistent
- Participate in team based support and contribute to ongoing
program design and development as lessons are learned from the
field and process improvement work in performed within in the
- Initiate/maintain professional development plan including goals
for self-improvement and to sustain clinical and NYULMC
competencies; attend and participate in program/initiative
teleconferences, program enhancement trainings and meetings, as
- Meet all other expectations and responsibilities of the
program/initiative agreement as related to care coordination.
- Work in an ever evolving environment that can include
telemedicine, phone based support, and in-person care in clinics,
in the field and the community.
- Facilitates physician discussion with medical director of third
party payer in an attempt to overturn potential denial.
- Assists in the appeal process (concurrently and
retrospectively) for appeal of days and procedures.
- Documents clinical reviews in Allscripts, and forwards same to
appropriate payer as necessary.
- Communicates salient clinical parameters through chart
- Facilitates clinical managed care reviews to avoid technical
- Collaborates with the physicians and interdisciplinary care
team regarding expected LOS for specific patients utilizing MCG
criteria and Medicare benchmarks. Ensures that the team is actively
working towards transition to the next level of care and identified
expected discharge date.
- Prevents length of stay delays by recognizing when the acute
level of care is no longer necessary and continued ongoing
testing/treatment can be rendered on an outpatient basis, working
with the clinical staff to ensure that such services are scheduled
and approval obtained to facilitate the appropriate discharge and
- Facilitates efficient care processes and follows through on
delays in work-up, treatment and/ or discharge. Expedites
testing/procedures to prevent avoidable delays and facilitate
movement towards next level of care.
- Refers potentially avoidable days to physician advisor when
- Discusses medical necessity, as identified by the use of
clinical criteria, with the interdisciplinary team to facilitate
timely movement to the next level of care
- Assesses appropriateness of patients admission, need for
continued stay, level of inpatient care and discharge level of
- Acts as a resource to physicians/ staff regarding MCG criteria
for top DRGs on CMs unit
- Coordinates post discharge appointments with PCP to ensure
cross continuum continuity of care.
- Communicates promptly and effectively with responsible medical,
nursing and ancillary staff to ensure documentation adequately
reflects patient clinical status, admission status and need for
- Monitors patient progress toward goals
- Provides informal education for hospital personnel that enhance
their knowledge regarding clinical pathways, reimbursement issues,
federal/state regulations, discharge planning issues and early
recognition of post-hospital needs.
- Encourages and facilitates high level of collaboration with
medical staff, interdisciplinary team, and agencies contracted to
provide continuing care services.
- Demonstrates knowledge of disease process, available resources,
and treatment modalities, assessing their quality and
appropriateness for specific disabilities, illnesses and
- Avoids potentially unnecessary days through the timely
completion of the PRI and home care transfer documents. Documents
avoidable days in the Allscripts system.
- Identifies potentially unnecessary days and discusses plan of
care with treatment team to reduce or eliminate same. Escalates
problem as per process to eliminate delays as possible.
- Prepares and updates PRI, using Allscripts, to reflect current
changes in patient status.
- Ensures post discharge plan of care is appropriately
coordinated with and communicated to providers of post discharge
care including but not limited to significant others, SNF and home
- Demonstrates ability to implement an alternative plan for
discharge when modifications are required.
- Coordinates and ensures that the interdisciplinary plan of care
and the discharge plan are consistent with the patients clinical
course, continuing care needs and covered services
- Identifies barriers to care and discharge and presents
information to appropriate operational leaders to assist in the
development of strategies for improvement
- Anticipates and/or identifies discharge planning issues and
effectively collaborates with the social worker, patient accounts
representative, home care and /or skilled nursing facility liaison,
other outpatient care representatives to address needs such as
financial aid and/or post-acute service arrangements.
- Works to ensure that patient outcomes are achieved within
established timeframes using appropriate resources.
- Demonstrates an ability to identify and shift priorities within
work assignment to effectively manage patient care load.
- Collaborates daily with interdisciplinary team for assigned
patients to discuss patient care planning and care
- Discusses estimated length of stay, treatment and discharge
plan with the attending physician and patient/family. Initiates
discharge planning at the time of admission, and continues
throughout the inpatient stay.
- Performs other duties as assigned or volunteered in alignment
with medical center mission, goals and valuesMinimum
Qualifications:NY State RN licenseBSN required.At least five years
relevant clinical experience with demonstrated leadership skills
required.Masters Degree in Nursing preferredCase Management
certification preferred.PRI certification preferredExperience in
Quality Improvement, Utilization Management, Case Management
preferred.Microsoft Office skills required, database/spreadsheet
skills preferred.Ability to learn computer programs as
needed.Willingness to devote the time required completing assigned
tasks on schedule.. Qualified candidates must be able to
effectively communicate with all levels of the organization.NYU
Langone Hospital - Brooklyn provides its staff with far more than
just a place to work. Rather, we are an institution you can be
proud of, an institution where youll feel good about devoting your
time and your talents.NYU Langone Hospital-Brooklyn is an equal
opportunity and affirmative action employer committed to diversity
and inclusion in all aspects of recruiting and employment. All
qualified individuals are encouraged to apply and will receive
consideration without regard to race, color, gender, gender
identity or expression, sex, sexual orientation, transgender
status, gender dysphoria, national origin, age, religion,
disability, military and veteran status, marital or parental
status, citizenship status, genetic information or any other factor
which cannot lawfully be used as a basis for an employment
decision. We require applications to be completed online.If you
wish to view NYU Langone Hospital- Brooklyns EEO policies, please .
Please to view the Federal "EEO is the law" poster or visit for
more information. To view the Pay Transparency Notice, please
Keywords: NYU Langone Health, New York , Case Manager Family Health Centers Brooklyn- RN required, Executive , Brooklyn, New York
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