Nurse Case Manager
Maimonides Medical Center
Nurse Case Manager
Maimonides Medical Center
Independent teaching hospital delivering specialized care
Partners with the Social Worker/Social Worker Assistant to form the clinical case management team. Develops, plans, organizes, implements, coordinates, monitors and evaluates activities related to the outcome management of patients through the Continuum of Care from admission to post-discharge; acts as liaison with nursing, medical staff and other clinical departments to integrate the Department’s functions and services with other aspects of the patient care process.
For direct care providers: Provides age-appropriate care and intervention for ages of patients served according to job description (e.g., assessments, treatment plans, assists with assessments).
[ ] For non-direct care providers: Provides support services using age appropriate interpersonal communication.
1,3 Coordinates discharges that require services of a certified home health agency.
1 Negotiates with vendors, providers, and home care agencies to optimize services.
1,4 Collaborates with managed care companies to facilitate appropriate use of benefits and services to patients (e.g., obtains optimum coverage for patients while in hospital; negotiates appropriate nursing home/home care services with company-approved agencies or arranges for use of alternate agency).
1,3 Functions as clinical resource person for the multidisciplinary health care team, patient and family on insurance benefits, managed care process, clinical and utilization review issues in order to maximize quality of patient care and effectively manage length of care.
1,2 Applies appropriate third-party payor procedures regarding financial coverage, non-coverage and alternate level care. Explains and distributes notifications to patient and/or family representative.
1,5 Completes all forms required for discharge in a timely manner (e.g., Patient Review Instrument).
1,3,4 Reviews all admissions within 24-48 hours to ensure they are appropriate for acute care and are made to the appropriate setting. Identifies potential treatment and discharge problems (e.g., required treatment is not performed at Maimonides Health, patient has no appropriate place to go on discharge). If admission is assessed as inappropriate, consults with responsible physician to clarify the plan of care. Completes assessment for patient discharge planning needs within 24 hours.
1,3 Acts as a liaison with nursing and medical staff and other clinical departments to integrate the department's functions and services with other aspects of the patient care process.
1,3 Consults and collaborates with physicians and other members of the health care team to coordinate plan of care, determine the most cost-effective use of hospital resources, and remove obstacles for timely, efficient discharge.
1,2 Collects and analyzes patient data to advise the health care team on appropriateness of care, patient outcomes and other relevant continuum of care issues.
1,2,3 Key member of Interdisciplinary Team (IDT) rounds.Provides key information to IDT team in regards to DRG, GMLOS, confirm projected discharge date, ensures appropriateness of continued stay, updates the team on discharge planning and any obstacles to discharge identified. Works with team to ensure that all required documentation is provided to ensure early and timely discharges. Escalates any barriers to discharge to management if not resolved timely.
1,2,4 Identifies potential Alternate Level of Care (ALC) (sub-acute) patients; consults with admitting physician to determine the need for acute care admission and discuss alternate plan of care; collaborates with health care team to arrange appropriate placement and ensure appropriate documentation is completed. Validates ALC status with finance and any other stake holders identified.
1,3 Maintains a leadership role in the health care team to ensure high quality patient care; identifies health care team educational needs and participates in developing and implementing programs; coordinates multidisciplinary rounds, referrals and case/family conferences. As the clinical lead on the case management triad, maintains ongoing communication with the Social Work Assistant (SWA) to ensure all facets of the discharge plan are completed. This includes off-loading tasks from the SWA’s and completes them. (e.g., Creating referrals for post-acute services, update discharge planning page, arranging transportation etc.).
1,2,3 Ensures participation of patient/family in treatment plan process, including setting realistic goals based on patient's clinical status. Communicates with patients/families to facilitate post-acute care plan. Confirms with family the discharge disposition, date and time for those patients who request it as well as those patients who do not have capacity.
1,2,5 Coordinates patient care with all hospital departments, community agencies and extended care facilities; acts as a liaison with other organizations to assess appropriateness of transfers. Ensures appropriate clinical documents necessary for post-acute placement are included within the referral.
2,3,4 Provides verbal and written explanation of patient’s plan of care, discharge plan, and post-discharge plan of care, encouraging patient and family to participate in plan development; assesses patient and family understanding of all plans. Provides patient/families choice for post-acute providers when indicated. Documents ongoing discharge planning process and discussions in patient medical record. Reviews with the SWA to ensure that discharge planning page in CarePort, is current and accurate for reporting purposes. In collaboration with the SWA, ensures that discharge planning documentation is current and up to date. As the clinical lead, should discuss with SWA when they need support to complete the activities of the day.
1,3,4 Performs monthly chart reviews. Monitors length of stay, timely scheduling of tests/consultations and reports barriers to department leadership for intervention. Participates in Performance Improvement activities, e.g., submits daily discharge stats and weekly statistics.
1,3,5 Identifies, refers and consults with Social Worker, patients with complex discharge problems of domestic violence, sexual assault, child abuse and elder abuse, etc.
1 Participates in developing and implementing clinical practice guidelines; participates on interdisciplinary and external committees.
1,5 Assessment and patient care responsibilities are delivered with knowledge of patient growth and development and are appropriate to the ages of the patients served.
1,6 Maintains established departmental policies and procedures, objectives, performance improvement program, safety, environmental, and infection control standards.
1 Completes any additional ancillary tasks related to discharge planning as needed or directed by case management leadership.
1,6 Customer Service: respect, flexibility, knowledge, confidence, professionalism, pleasant attitude, patience and helpfulness. All responses should be timely, professional, caring, and respectful in accordance with Customer Service Performance expectations.
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OTHER JOB DUTIES
Provides general support to case management process (e.g., faxes documents, arranges team meetings);
Arranges for ambulance, ambulette or car service as directed by MD/Nurse Case Manager; obtains necessary prior approvals.
Professionally directs activities of support persons, volunteers, students, Community Senior Aides and others as needed. Participates in studies, surveys or research, initiated or approved by the Case Management Department in order to develop knowledge about effective treatment, or improve quality of delivery of service/care. Identifies quality of care issues and refers to appropriate departments/services. Participates in conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise. Participates in multidisciplinary task forces, committees and projects. Performs other related duties as required.
Education:
BSN required-Masters preferred. Degree in Nursing or an allied health field, or a suitable combination of education and experience required.
Current NYS licensure as RN required.
Experience:
Minimum of 3 years of direct experience in utilization management, discharge planning, case management
or home care management preferred.
Skills:
Current clinical and technical nursing skills.
Knowledge of rules and regulations of child abuse/neglect reporting as appropriate.
Familiar with the requirements of regulatory agencies and third-party payors.
Demonstrates the ability to use word processing, spreadsheet and/or database programs as required by the position.
Excellent oral and written communication skills.
Excellent interpersonal skills.
Independent teaching hospital delivering specialized care
Maimonides Medical Center is the largest hospital in Brooklyn, offering comprehensive inpatient and outpatient care across many specialties, plus a Children’s Hospital with a Pediatric ER, Pediatric ICU, and Neonatal ICU. Care is delivered through specialized departments (Cardiac, Neuro, Thoracic, Urology, Orthopedics, Surgery) within an independent teaching hospital that combines treatment with education and research. It stands out for excellent CMS outcomes in heart attack, heart failure, and pneumonia, and for delivering more babies in New York State than any other hospital, with strong pediatric and neonatal care. Its goal is to provide high-quality medical care while training future physicians and advancing medical knowledge through teaching and research.
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