Job Location : New York,NY, USA
NYC Health + Hospitals/Metropolitan is the community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities. The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan delivers high quality health services with compassion, dignity, and respect to all, without exception. Since its founding in 1875, the hospital has been affiliated with New York Medical College, representing the oldest partnership between a hospital and a private medical school in the United States. Metropolitan is a part of the NYC Health + Hospitals, the largest municipal hospital and health care system in the country. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons. Work Shifts 9:00 A.M - 5:00 P.M Duties & Responsibilities PURPOSE OF POSITION: Under general supervision, with varying degrees of latitude for independent initiative and judgment, coordinates and monitors the management of patient-centered quality care, ensuring optimal utilization of resources, service delivery, and compliance with external review requirements and applicable state and federal rules and regulations and nursing standards of care for better outcomes and improved patient experience. Facilitates patient's progress from admission through discharge, and promotes strategies and forums for collaboration and mutual problem solving. RESPONSIBILITIES: • Complies with Metropolitan Hospital Center policies and procedures • Perform Inpatient Utilization Review: Where indicated, perform initial and continued stay utilization review using evidence-based clinical assessment tools per payor stipulations to determine medical necessity of services and ensure compliance with regulatory standards. • Manage Medical Necessity Documentation: Review medical record, and partner with physicians, nursing, and other care team staff to ensure accurate, thorough, and timely documentation supporting ongoing level of care and appropriateness of services provided. • Manage Ongoing Payor Communication: Communicate with payor clinical teams to facilitate initial/ongoing reimbursement authorization/certification for assigned inpatients, provide additional clinical information as needed, and identify cases requiring Peer to Peer resolution. • Participate in Interdisciplinary Rounds: Facilitate and/or participate in interdisciplinary rounds for assigned inpatients, and review plan of care, expected length of stay relative to goal, need for continued hospitalization, and discharge bottlenecks and delays. • Assess & Facilitate Post-Acute Services: Assess post-acute level of care needs and facilitate appropriate services. Engage with patients/caregivers, complete the Patient Review Instrument (PRI), obtain prior authorization, place referrals, and support transfer needs as applicable. • Address Potential Discharge Delays: Identify and address issues/gaps in care that increase risk for discharge delays, avoidable hospital days, or hospital readmission, and partner with care team members to resolve them appropriately. • Support Care Plan Coverage Needs: Support and educate patients/caregivers and hospital care teams to payor policies, covered services, and benefit limitations, and support patient changes to coverage as appropriate to support care plan needs. • Educate Patients on Health Management: Work with patients/caregivers to deliver culturally-competent education to improve health literacy and self-management of care, including on disease prevention/management, medication administration, and post-discharge care. • Review Denials and Support Appeals: Conduct clinical review of assigned case management denials for appealability, and work with physician and hospital staff appealers and finance teams to ensure timely and high-quality Peer-to-Peer and written appeals. • Review Short-Stay Level of Care: Conduct retroactive pre-billing clinical review of assigned short-stay admissions to determine appropriate level of care and make initial recommendations on appropriate level of care, in partnership with UM leadership. • Support Staff Training/Education: Support in education and onboarding of new inpatient care management staff and act as an educational consultative resource regarding inpatient care management to interdisciplinary partners in the inpatient setting. • Participate in Quality Improvement: Participate in development, implementation, evaluation, and revision of departmental operations and policy standards, including developing and implementing quality assurance and improvement initiatives. • Maintain Timely Documentation: Completes and maintains all required documentation, including but not limited to utilization review documentation, clinical assessments, care coordination activities, external correspondence, and discharge planning. Minimum Qualifications 1. Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED); and 2. A Baccalaureate degree in Nursing or related health field from an accredited college or university; and 3. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA); and 4. Two (2) years of experience as a Registered Professional Nurse. Benefits NYC Health and Hospitals offers a competitive benefits package that includes: