RN Case Manager (Medicare) Job in 10004

* Job Title: RN Case Manager (Medicare)
* Company: Healthfirst
* Location: 10004
* Job Category: Medical/Health
* Career Level: Experienced (Non-Manager)

* Company: Healthfirst
* Reference Code: heal-00001478



Healthfirst is a not-for-profit managed care organization with a unique hospital-managed business model'allowing us to successfully deliver state and federally subsidized quality healthcare to more than 480,000 members through a network of close to 20,000 physicians and specialists.

Operating in the five boroughs of New York City, Long Island and Westchester County in New York, and in Bergen, Essex, Hudson, Passaic and Union counties in New Jersey, Healthfirst has partnered with our participating hospitals to develop a solid and effective approach to meeting the ever-changing needs of the medically underserved.

What's more, strong relationships with community-based organizations, schools, advocacy groups, local politicians, hospitals, governmental agencies and businesses allow Healthfirst to stay abreast of healthcare needs within the communities we serve and develop programs to meet them.

Everyone at Healthfirst is committed to our members. Our Quality Improvement and Medical Management departments continue to develop effective and efficient treatment programs that maximize safe clinical practices and enhance service delivery while our participating providers ensure that members receive the highest possible quality care. As result, Healthfirst is the #1 Medicaid plan in New York State in terms of clinical quality.

RN Case Manager (Medicare)

Established in 1993, Healthfirst is a hospital-sponsored organization dedicated to providing the highest possible care, access and customer service to its members. Headquartered in New York City, Healthfirst offers a variety of Medicaid, Medicare and commercial healthcare programs. Over 85 hospitals and medical centers and close to 20,000 physicians and specialists make up the Healthfirst provider network. With over 1,800 employees, the Healthfirst family of companies includes Healthfirst in New York, Healthfirst NJ in New Jersey, and HF Management Services, which provides comprehensive administrative services to healthcare organizations in New York, New Jersey, and Florida.

At Healthfirst, employees are the company and the key to our success. As Healthfirst continues to grow, we take pride in our diverse staff that believes in our mission to improve the health status of low income individuals and families by increasing access to high quality healthcare, providing great customer service, and addressing individuals' total healthcare needs. In an ever changing industry, once you become a Healthfirst employee it is our goal you continue developing your career within our team. If you thrive in a diverse, fast paced, friendly, and quality driven environment, consider joining the Healthfirst family and improve the healthcare delivery system every day.

The RN Case Manager is responsible for assisting with the development, organization, implementation, monitoring and evaluation of activities related to the outcome management of assigned patients. Acts as a resource, consultant, and educator to all staff in the planning and delivery of patient care within the Network.

DUTIES AND RESPONSIBILITIES:

' Uphold and support the philosophy, goals, and objectives of the Medical Management department at Healthfirst to provide quality, cost-effective care to all members.
' Assume a leadership role in the multi-disciplinary care team in order to insure high quality patient care and appropriate allocation of member services and resources.
' Conduct educational programs for all members of the Healthfirst team, which support the continued growth of activities that are focused on measurable patient outcomes.
' Maintain and develop professional competence via participation in professional organizations and continuing education programs.
' Manage patient care with Medicare members, their families or significant others and coordinate with the PCP, SCP and all members of the health care team facilitating the patient's care across continuums of care episodes.
' Perform preadmission, concurrent, and retrospective reviews to evaluate appropriateness of admission, need for continued stay, length of stay, utilization of resources, patient outcomes, and usage of other services post encounter.
' Recommend changes in-patient care practices.
' Identify opportunities for and facilitate member transfer to: a) hospital of enrollment/other appropriate in-network hospital when hospitalization occurs out-of-network; or b) hospital of enrollment when hospitalization occurs at another network hospital.
' Evaluate and pre-authorize request for inpatient/outpatient, specialty care, home care, DME, and transportation services from network and out-of-network providers in accordance with departmental guidelines.
' Collect and evaluate data and statistics based on identified indicators and recommend changes in-patient care practices.
' Participate in research and quality monitors in order to improve practice patterns.
' Function as a clinical resource person/educator for the multi-disciplinary health care team on an ongoing basis in order to maximize quality of patient care, effectively manage length of stay and utilization of resources.
' Maintain open lines of communication with an emphasis on supportive collegial relationships.
' Act as a resource/educator/liaison to all levels of staff both internally at Healthfirst and in the network regarding Healthfirst medical management policies and procedures.
' Coordinate resources allocation which maximizes efficiency within the network while maintaining cost containment.
' Assist in the development of patient care standards.
' Assist with identifying opportunities for and facilitating alternative care options based on member needs and assessments.
' Perform other related duties as required.
' Assess all inpatient, emergency and ambulatory care for appropriateness of setting and services according to preestablished criteria and guidelines.
' Assess member's physical, psychosocial and discharge planning needs through communication with appropriate hospital staff including attending practitioner, utilization review staff, discharge planners, social workers, and coordinates care accordingly.
' Contribute to the development of policies and procedures.
' Responsible for compliance, in practice, with regulatory mandates.
' Contribute to the development of patient focused of care and initiates the process as per established guidelines.
' Document all interventions and all telephone encounters with providers, members, and vendors in the appropriate system in accordance with established documentation standards to insure integrity of member services provided over the continuum and over time.
' Document and close all authorizations and make a determination as to whether the requested services should be paid or referred for possible denial to insure expeditious claims processes.

SKILL SETS:

' Effective verbal communication skills, appropriate, professional conversational telephone manner
' Ability to apply nursing process and systems theory to problem solving activities
' Familiar with current relevant medical standards of practice
' Knowledge of concepts and philosophy of Case Management and regulations of utilization review
' Good writing and excellent telephone assessment skills
' Ability to serve as a liaison and educator, and coordinate resources on a continued basis
' Ability to assess appropriateness of inpatient care

EXPERIENCE:

Minimum of 2 years clinical experience, or previous Case Management, Utilization Management experience dealing with Medicare populations.

EDUCATION:

Graduate of an accredited nursing program with a RN certificate
Baccalaureate degree preferred

OTHER REQUIREMENTS:

Licensed to practice as a registered nurse in the state of New York with current registration.

Evidence of continuous education in patient care management and case management. Knowledge of concepts and philosophy of Case Management and regulations of utilization review required
Experience in a managed care environment.


For consideration apply online at www.healthfirstny.com

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