Registered Nurse, Care Manager (Utilization Management), Per Diem New York, NY - NYU Langone Health : Job Details

NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across 6 inpatient locations, its Perlmutter Cancer Center, and over 320 outpatient locations in the New York area and Florida. With $14.2 billion in revenue this year, the system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise with over $1 billion in active awards from the National Institutes of Health.

Position Summary: We have an exciting opportunity to join our team as a Per Diem - Care Management (UM). In this role, the successful candidate coordinates, negotiates, procures, and manages the care of patients by providing focused care coordination across the acute care continuum. Evaluates appropriate clinical resource utilization, and assesses patients for transitioning to the next appropriate level of care through review of patient records and information derived from interdisciplinary rounds. Collaborates with the health care team to ensure the achievement of quality outcomes for patients/families.

Job Responsibilities:

• Identifies cases that require peer review in accordance with the clinical indicators and criteria developed by the clinical department. Identifies trends in care, processes or services that may provide opportunities for improvement in a patient population or clinical service. Refers appropriately cases that require peer review in accordance with the clinical indicators and criteria developed by the clinical department. Takes initiative to participate in a quality/process improvement initiative. Collaborates with the interdisciplinary team to create solutions and take corrective actions to address issues resulting in variances in the plan of care.
• Applies customary protocols, pathways, evidence-based processes and other means of managing patient care. Utilizes protocols, pathways and order sets to formulate, communicate and ensure implementation of the patient plan of care. Utilizes multidisciplinary team to address individualized patient needs. Develops realistic goals with multidisciplinary team for patient to achieve milestone activities within appropriate timeframes. Demonstrates flexibility with plan of care to meet patient needs.
• Supports the mission, philosophy, standards, goals and objectives of NYU Hospitals Center and Care Management Program. Contributes to the development of the goals and objectives of the Care Management Program consistent with the objectives of NYU Hospitals Center. Understands, applies and supports departmental/hospital policies, procedures and standards. Observes at all times legal and ethical considerations pertaining to patients and hospital personnel. Initiates programs for improving cost effectiveness in coordination of patient care. Assists managers to create a participative environment in department based meetings and other activities. Analyzes and develops systems to improve processes and outcomes in collaboration with managers.
• Communicates the outcome of chart review and managed care company telephonic review with the health care team as appropriate. Conducts accurate reviews using CMS, Milliman Care Guidelines and the patients chart as the primary source of information. Performs and documents initial certification and continued stay reviews within appropriate time frame and in appropriate system. Documents obtained payor authorization in a complete, timely and concise manner. Maintains follow-up communication with payor as required for authorization of hospital stay. Notifies health care team of outcomes of communication with payor and authorization status. Notifies departmental manager of all unresolved utilization problems/issues.
• Acts as advocate/facilitator in all cases with insurance related issues, delays in treatments and/or diagnostic tests. Collaborates with the interdisciplinary team to maintain appropriate levels of care to facilitate movement of the patient through the continuum. Identifies and documents delays in treatment and processes. Understands basic reimbursement systems and identifies potential payor issues relative to delays in treatments and/or diagnostic tests. Assists in developing strategies to decrease avoidable days. Demonstrates and communicates the value of avoidable days and/or additional documentation to justify acute inpatient hospitalization.
• Participates in departmental, interdisciplinary, hospital and Medical Board committees as appropriate. Represents the voice of Care Management in committee participation. Completes committee assignments as requested. Provides feedback and periodic reports to Care Management at departmental meetings and senior managers on relevant issues.
• Assesses patient and medical record documentation for appropriate acute admission and level of care, quality and safety indicators, and plans for discharge. Assesses patient and medical record documentation to identify medical necessity and appropriateness of admission and continued stay using pre-established clinical criteria (i.e., Milliman Care Guidelines, CMS) according to hospital policy. Ensures that the physicians documentation supports level of care. Collaborates with physician when additional documentation needed to support level of care. Communicates appropriate level of care to the health care team. Utilizes patient assessment information to identify quality and safety indicators to monitor during hospital stay. Performs initial and ongoing assessment of patient/family needs for discharge planning and communicates findings to interdisciplinary team.
• Performs systematic assessment and reassessment of patient and family/significant other considering clinical presentation, cultural and religious influences, individual experiences, available resources, environmental factors as well as health behaviors and practices. Considers all aspects of patient/family assessment findings. Understands medical plan of care and is able to communicate pertinent findings from patient assessment. Monitors medical plan of care to determine outcome of treatment and revise patient assessment as necessary. Facilitates appropriate consults based on patient assessment to ensure timely delivery of care. Identifies cultural and religious influences on illness.
• Formulates the plan of care, along with the patient and family, based on communication with the attending physician(s), expected goals of care and length of stay; articulates knowledge of the plan of care through an understanding of patients diagnosis, prognosis, care needs, and desired outcomes. Considers assessment findings and collaborates with the attending physician (s)/hospitalist to establish the expected goals of care and LOS. Collaboratively participates in the development of an interdisciplinary plan of care that is individualized to the patients condition or needs. Focuses the care plan on quality of life, effective utilization of resources, and facilitates goal achievement and movement through the continuum of care. Proactively identifies hospital services and available resources to meet patients needs. Reviews patient history and re-assess prognosis and care needs to achieve desired outcomes. Assesses patient/family needs for advance care planning. Confers with attending physician/hospitalist and health care team regarding variances from anticipated plan of care.
• Works collaboratively with attending physician, consulting physician(s) and other disciplines to identify, develop, implement and coordinate an appropriate plan of care that maximizes individual patient/family preference and enhances quality, access, and cost-effective outcomes. Ensures patients individualized plan of care is collaborative and multidisciplinary by working with patient/family, attending physician/hospitalist and health care team members. Coordinates care based on individual needs, expected goals and length of stay. Facilitates interdisciplinary plan of care interventions. Communicates effectively with attending physician/hospitalist and members of health care team to enhance patient care in a positive environment.
• Assesses patient and family responses to interdisciplinary plan of care and care management interventions, and adapts interventions to achieve optimal outcomes. Collaborates with patient, family, interdisciplinary team for agreement with treatment goals, timeframes and coordination of care. Works with the interdisciplinary team to facilitate adjustments to the care plan to promote enhanced outcomes. Intervenes as care manager in a manner that is consistent with the established plan of care. Prioritizes and organizes interventions. Implements interventions in a safe, timely and appropriate manner.
• Documents assessments, findings, progress, interventions and recommendations in a care management software system and/or medical record according to established standards. Documentation meets standards in accordance with departmental and hospital policy and procedures. Documents assessments, findings, progress, interventions and recommendations in Canopy and ECIN Care Management and ICIS systems within established timeframes. Documents revisions in diagnoses, plan of care and outcomes. Documents patients responses to interventions with appropriate consideration of patient confidentiality.
• Contributes to the development of new strategies to address transitional planning needs of specific assigned patient populations, improved care coordination and care management delivery. Utilizes current literature to facilitate clinical/care management practice changes. Participates in the development and revision of clinical/care management practice standards. Engages in strategies to measure improvements in quality of care that directly result from care management interventions. Utilizes evaluative and outcomes data to improve care management services.
• Participates in development of quality indicators and analysis of such indicators per departmental quality & performance improvement plan. Collaborates with members of the interdisciplinary team to develop quality indicators to measure performance improvement per departmental quality & performance improvement plan. Conducts required and initiated monitoring activities report to respective disciplines as indicated. Evaluates outcomes of monitoring, and adjusts targets and reporting as indicated. Facilitates and ensures sharing of data and outcomes with interdisciplinary team.
• Uses evidence-based practice to drive improvement strategies. Promotes health care outcomes in conjunction with evidence-based guidelines. Identifies areas requiring further study. Develops strategies to utilize data findings for individual patients as well as program. Recommends interdisciplinary evidence-based practice changes.
• Facilitates effective coordination of interdisciplinary unit/physician team (e.g., Firm on the Medical Service) rounds to identify the patients clinical management needs, progression of care,