Nurse Case Manager

Description
Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care. Non-acute care is offered through various affiliates,

Position Summary -

Discharge Planning for the ER and Observation units

Under the general supervision of the Director, The Nurse Case Manager role provide clinically-based case management to support the delivery of effective and efficient patient care.

Paces the case from physiological and economic perspectives.

Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.

Utilizes criteria to confirm medical necessity for admission and continued stay.

With the patient, family and health care team, creates a discharge plan appropriate to the patient's needs and resources.

Essential Duties And Responsibilities

• Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria, computer system or third party information to resolve the situation. Documents information in the current electronic system (such as MIDAS).
• Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate. o The observation cases are a priority and at a minimum the case manager reviews observation cases daily.
• Utilizes physician advisor to interface with physicians as needed.
• Collaborates with the third party payers to anticipate denial of