ED RN Case Manager | Evening

Position Summary

At Stony Brook Medicine, the TH Staff Associate/RN Case Manager – Emergency Department is a valuable member of the interdisciplinary care team who provides clinical case management, utilization management, and care coordination services to patients presenting to the Emergency Department.

The RN Case Manager works collaboratively with Emergency Department physicians, nursing, Social Work, Care Management, hospital leadership, and other members of the healthcare team to evaluate patients for the most appropriate level and setting of care, facilitate timely patient progression, and identify opportunities for safe discharge or transition from the Emergency Department.

Using clinical judgment, nationally recognized criteria including MCG, payer requirements, and applicable regulatory guidelines, the RN Case Manager evaluates medical necessity and appropriate level of care, including inpatient, observation, emergency, and outpatient services.

The RN Case Manager also identifies patients with complex discharge needs or barriers to care and facilitates appropriate services, resources, and follow-up to promote safe transitions, reduce avoidable hospital admissions and readmissions, and support efficient patient flow through the Emergency Department.

Qualified candidates will demonstrate superior clinical judgment, communication, collaboration, and organizational skills while adhering to our high standard of excellence.

Duties of a TH Staff Associate/RN ED Case Manager may include the following but are not limited to:

• Screen patients presenting to the Emergency Department to determine medical necessity and the most appropriate level and setting of care, including inpatient admission, observation, continued emergency care, or discharge with appropriate services and follow-up.
• Apply MCG criteria in conjunction with clinical judgment, physician documentation, payer requirements, and regulatory guidelines to support level-of-care determinations.
• Collaborate with Emergency Department physicians and the interdisciplinary team regarding patient status, medical necessity, and appropriate disposition; identify cases requiring additional review or escalation when established criteria are not met.
• Perform initial utilization review and assist with payer notification, authorization, and clinical documentation requirements for patients requiring hospitalization or observation services.
• Identify patients who may be safely treated in a lower level or alternative setting of care and collaborate with the healthcare team to facilitate appropriate disposition.
• Conduct timely case management assessments to identify high-risk patients and patients with complex medical, functional, psychosocial, financial, or discharge planning needs.
• Initiate and coordinate discharge planning directly from the Emergency Department, including home care, durable medical equipment, rehabilitation services, skilled nursing placement, transportation, community-based services, outpatient follow-up, and other resources as appropriate.
• Identify barriers that may delay or prevent a safe discharge and collaborate with physicians, Social Work, nursing, patients, families, and community providers to develop an appropriate transition plan.
• Identify patients with frequent Emergency Department utilization, recent hospitalizations, or other indicators of increased risk and collaborate with the interdisciplinary team to develop strategies to address identified needs and promote continuity of care.
• Facilitate communication with patients and families regarding the plan of care, discharge needs, available resources, and transition-of-care planning.
• Promote efficient patient flow by identifying and addressing barriers to disposition and facilitating timely transitions from the Emergency Department to the appropriate care setting.
• Collaborate with inpatient Case Management when patients require admission to ensure continuity of care, communication of identified needs, and an effective transition from the Emergency Department.
• Maintain accurate and timely documentation of utilization review activities, level-of-care determinations, case management assessments, interventions, discharge planning activities, and patient disposition.
• Identify trends, barriers, and opportunities through data collection and review to support appropriate utilization of services, improved patient flow, reduced avoidable admissions/readmissions, and high-quality patient care.
• Maintain knowledge of CMS requirements, payer policies, regulatory standards, community resources, and Case Management/Utilization Management best practices.
• Provide a safe, efficient, patient-centered environment that promotes patient and physician satisfaction, timely patient flow, and high-quality customer service.
• Perform other duties as assigned.

Please Note: this position requires weekends and Holiday coverage.

Qualifications

Required Qualifications:

• Current New York State Registered Professional Nurse license.
• Bachelor's degree in Nursing or related field.
• Minimum of five (5) years of clinical nursing experience.
• Strong clinical assessment and critical-thinking skills with the ability to evaluate complex patient presentations and determine appropriate level of care.
• Computer proficiency, including Microsoft Office Suite and electronic medical record systems.
• Excellent communication, interpersonal, organizational, and collaboration skills.
• Demonstrated ability to work effectively with physicians, patients, families, and interdisciplinary healthcare teams.
• Strong customer-service skills.
• Ability to prioritize and manage multiple time-sensitive responsibilities within a fast-paced Emergency Department environment.
• Creative, flexible, professional, and courteous demeanor.

Preferred Qualifications:

• Case Management and/or Utilization Management certification.
• Five (5) years of Case Management and/or Utilization Management experience.
• Working knowledge of MCG (Milliman Care Guidelines) and/or InterQual criteria.
• Recent clinical, Case Management, or Utilization Management experience in an Emergency Department and/or tertiary care hospital.
• Experience performing medical-necessity and level-of-care determinations.
• Experience with discharge planning, transitions of care, and coordination of post-acute and community-based services.
• Knowledge of payer authorization and regulatory requirements.
• Master's degree.
• Management or supervisory experience.
• PRI certification.
• Bilingual

Special Notes: Resume/CV should be included with the online application.

Posting Overview: This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and