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Northwell Health Case Manager RN PD (FH) - LIJFHH (Per Diem) in Forest Hills, New York

Req Number 003B2G

Job Description

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font-weight:normal"Coordinates and facilitates patient care throughout hospitalization.

  • Performs a case management intake assessment.

  • Orients patient to the role of the case manager, the goals of care and expected length of stay.

  • Discusses with attending physician and/or physician advisor the appropriateness of resource utilization, consultation and treatment plan.

  • Participates in interdisciplinary patient care rounds.

  • Discusses estimated length of stay, treatment and discharge plan with the attending physician, as indicated.

  • Identifies and assists in removing barriers to patient care (variances) and resolves issues with appropriate departments and staff.

  • Coordinates and facilitates transitional planning needs through the acute care continuum.

  • Makes referrals to social work as identified through the high risk screening process using high-risk criteria,.

  • Consults with the physician regarding physical therapy, nutrition, speech therapy, respiratory therapy and other ancillary services as needed.

  • Collaborates with members of the interdisciplinary team to assess, plan, implement, coordinate and monitor services required to achieve quality patient care and resource management.

  • Serves as liaison between patients, families, physicians, payers and other members of the interdisciplinary care team.

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font-weight:normal"Coordinates and facilitates the discharge planning


  • Initiates discharge planning by assessing the patient's needs and documenting the assessment on the interdisciplinary care team.

  • Works collaboratively with the physician and interdisciplinary team to determine the patient's need for continuing care services.

  • Ensures interdisciplinary care plan and discharge plan are consistent with the patient's clinical course, continuing care needs and covered services.

  • Conducts a case management assessment including the patient's physical, psychosocial and financial needs and issues.

  • Interviews patient or designated agent to assess discharge-planning needs.

  • Involves patient and/or family in discussion and planning for anticipated need for care following discharge.

  • Ensures discharge plan is safe and timely.

  • Completes paperwork and/or ensures paperwork is completed and distributed.

  • Ensures patient and/or family are given information regarding their choices regarding transfer to another level of care according to regulatory standards.

  • Ensures continuing care services including transportation, durable medical equipment, etc. are appropriately arranged for and financially approved.


font-weight:normal"Performs concurrent utilization management.

  • Reviews appropriateness of patient's admission, need for continued stay and discharge criteria using established criteria.

  • Discusses with attending physician and/or physician advisor the appropriateness of resource utilization, consultation and treatment plan.

  • Ensures patient meets acute care criteria during each in-patient day.

  • Places patient on alternate level of care (ALC) status In concert with attending physician.

  • Responds to third party payer requests for concurrent clinical information providing all relevant documentation to ensure reimbursement within expected time frames.

  • Disseminates documents of non-coverage when appropriate.

  • Ensures compliance with current state, federal and third party payer regulations.

  • Works collaboratively with on-site reviewers to transition patients to appropriate discharge settings.

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font-weight:normal"Participates in quality management of patient care


  • Identifies and collects quality data including pre-established quality screens, NYPORTS and core measures.

  • Identifies and reports quality issues to the department management.

  • Ensures minimum quality standards are met each day of hospitalization.

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font-weight:normal"Documents case management process in the medical record.

  • Documents on-going process of discharge planning including discharge assessment, plan and on-going evaluation and up-dates.

  • Provides summary note at time of discharge synthesizing the discharge plan and follow-up care needs.

  • Completes appropriate portions of Patient Discharge Instruction Sheet.

  • Completes and facilitates completion of the Patient Review Instruments (PRI) with other disciplines.

  • Completes case management intake assessment form.

  • Completes relevant documents including Patient Transfer Form.

  • Documents on-going case management progress notes in the medical record.

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Performs related duties, as required.

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Degree in Nursing, required. Masters Degree, preferred.



license to practice as a Registered Professional Nurse in New York State.


Patient Review Instrument (PRI) Certification and Screen

certification required



in Case Management, preferred.



five (5) years clinical experience as a registered nurse and prior case

management (including utilization management and/or discharge planning)