**Job Description** The Case Manager is responsible for all aspects of case management/ utilization review for an assigned group of inpatients, ED patients and Observation ( RETU) patients to determine the correct Level of care ( LOC), appropriateness of the admission and continued stay, assist in the development of the plan of care; ensure that the plan is implemented in a timely basis and identify the expected length of stay (ELOS). The case manager works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed to develop a plan of care which includes discharge planning, resource management, health education, and the provision of information as it relates to care management and the transition of care. The Case Manager actively participates in specific clinical initiatives focused on LOC, reducing the length of stay (LOS), improved efficiency and quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services. Responsible For A group of inpatients to determine the appropriateness of the admission and continued stay, assist in the development of the plan of care, ensure that the plan is implemented in a timely basis, and identify the expected length of stay (ELOS) and problem solves care transitions accordingly within the interdisciplinary health care team. **Qualifications** **Qualifications** + Bachelor's Degree in Nursing; Masters preferred. + Previous experience as in homecare, long term care or utilization review preferred. + Discharge Planner or Case Manager preferred. + Manager or a minimum of 3-5 years? experience as a RN in an acute care setting + Current NYS RN nursing license. + Name: Basic Life Saver (BLS) Issuing Agency: AHA + CCM certification preferred. Re-credentialing of CCM status expected. + PRI Certification (to be obtained within 1 year) Collective bargaining unit: NYSNA-SLW NYSNA at Mount Sinai St. Luke's and Mount Sinai West, BEZ - Utilization Management - WST, Mount Sinai West **Responsibilities** + Principal Duties and Responsibilities Principle Duties and responsibilities include, but are not limited to: • Review and advice for appropriate level of care using criteria sets (refer to designated site software), cases referred or who have Observation diagnosis, or other high risk diagnosis as well as readmissions. • Review all patients in RETU to insure they meet Observation criteria, assist with discharge or admit to next LOC with-in unit specified timeframes. • Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization. • Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay. • Oversee clinical throughput of patient, ensuring medical treatment plan, e.g., timely tests, consults. • Collaborates with Physicians and other clinicians to expedite diagnostic testing, treatment and consultations. • Documents all clinical reviews in using designated site software program. • Liaison with Physician Advisor. + Case Management: • Assessment of the patient’s clinical, psychosocial, and functional status in collaboration with the interdisciplinary team. • Identification and documentation of variances affecting the LOS and the discharge planning process. • Conducts follow-up of any delays in treatment or reporting of results. • Planning/developing specific goals with the physician, interdisciplinary team, and the patient and/or family. • Implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care. • Determine ALC status and track avoidable days. • Documentation of outcomes achieved and identified internal and external barriers. • Identifies reasons for readmissions and collaborates with interdisciplinary team on strategies to reduce readmission rate. • Appropriately identifies and refers cases to the physician advisor to support timely progression of patients along the continuum of care and (appropriate) discharge planning. • Interacts with patient/family to discuss plan of care and coordination of services based on clinical needs and available resources. + Utilization Review: • Maintains a working knowledge of the UR requirements of each payor within the patient population • Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion. • Provides clinical information requested by the managed care companies in accordance with contractual agreements. • Works collaboratively with physicians and managed care companies on concurrent denial appeals • Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor Medical Director as required. • Performs additional duties as assigned. + Discharge Planning • Responsible for assessment, communication and monitoring of discharge planning process in collaboration with the clinical nurse initiates the discharge planning process on admission. • In collaboration with Social worker, obtains authorizations from managed care companies for post-discharge services. • Assesses for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement. • Assist in having appropriate staff complete discharge forms in a timely manner. • Coordinates the Discharge Appeal process. • Liaison with financial department for current insurance coverage. • Collaborates and participates in concurrent denial and appeals process with all members of the interdisciplinary team. + Communication and Collaborative Relationships • Develops and maintains effective working relationships with interdisciplinary team and with managed care/community organizations. • Interfaces with other departments within the Hospital effectively. • Demonstrates a professional, courteous and respectful attitude in dealing with patients/families/care givers and members of the health care team + Educational/Professional Development • Participates in the development of unit based staff. • Meets regulatory, licensure and annual health assessment requirements. • Identifies own learning strengths and needs through ongoing self assessment • Utilizes learning resources. • Seeks educational opportunities to maintain and enhance competence within current advances in health care delivery and case management • Provides presentations and educational offerings as needed. • Participates in special projects and committees. • Attends relevant workshops, conferences and seminars • Demonstrates membership in professional and related organizations. • Demonstrates competence in case management and required information technology and systems. **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $63.2801 - $63.2801 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.