Accountable Care Manager - Nyc Health Hospitals : Job Details

Kings County Hospital Center has a rich legacy for its pioneering role in medicine. Today, with over 625 beds, our hospital remains on the cutting edge of technology and provides the most modern procedures with state-of-the-art equipment. Built in 1831 as a one room infirmary for publicly supported care of the sick, Kings County Hospital Center continues to be a leading healthcare facility whose mission is to provide care to everyone regardless of their ability to pay. The hospital provides a wide range of health services, and specialties are offered in all fields of modern medicine. More than 200 clinics provide a wide array of ambulatory care services.At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Work ShiftsSHIFT II 8:30am-5:00pm (Other Work Schedule)Job DescriptionPURPOSE OF POSITIONUnder general supervision, with varying degrees of latitude for independent initiative and judgment, coordinates and monitors the management of patient-centered quality care, ensuring optimal utilization of resources, service delivery, and compliance with external review requirements and applicable state and federal rules and regulations and nursing standards of care for better outcomes and improved patient experience. Facilitates patient's progress from admission through discharge and promotes strategies and forums for collaboration and mutual problem-solving.AREAS OF RESPONSIBILITIESConsistent with Corporate Job Description:The Accountable Care Manager is responsible for facilitating the patient's care throughout the healthcare continuum. The Care Manager interfaces with patients, caregivers, physicians, nurses, social workers, and other health team members, as well as external health care agencies community-based organizations, and other providers to expedite medically necessary, high-quality, cost-effective patient-centered health care in the appropriate level of care setting (Ambulatory Practice, ED, Observation, Inpatient, ICU, SNF/NH, Community, Home etc.). The Care Manager applies clinical expertise and medical appropriateness criteria (clinical guidelines, clinical pathways, InterQual, Milliman Guidelines, etc.) to resource utilization, revenue management, discharge planning, and care coordination.SUMMARY OF DUTIES AND RESPONSIBILITIESExamples of Typical Tasks:Reviews each patient's chart. Ensures that documentation in the medical record supports plan of care and justifies admission and continued stay.Coordinates and/or participates in multidisciplinary rounds: reviews plan of care, and discusses estimated length of stay (LOS), need for continued hospitalization and appropriateness of resources utilization, consultations, treatment plan and discharge plan. Completes Patient Review Instrument (PRI), Screen, and all other regulatory required documents.Collaborates and consults with physicians and other health care professionals to reach an efficient pathway of care taking and to identify, eliminate, and implement solutions to barriers, and collects and analyzes related data, as needed.Communicates with hospital investigation/reimbursement department and third party payers to obtain authorizations and ensure appropriate reimbursement and provides clinical reviews and updates to managed care companies, as needed.Plans and implements strategies to reduce length of stay, reduce resource consumption, and achieve positive client/patient outcomes. May coordinate the implementation of facility initiatives designed to increase revenue. Maintains all related records and documentation.Initiates discharge planning by assessing client/patient and family needs, including but not limited to identifying non-medical psychosocial needs and post-discharge medical needs. Informs patient and family of discharge planning options based on diagnosis, prognoses, resources, and preferences related to home care services.Coordinates and facilitates timely implementation of discharge plans for patients; assures timely completion of discharge, transfer, and referral forms, prescriptions, and discharge orders; arranges follow-up care, as appropriate.Performs or coordinates the post-discharge phone call to patient and health care providers to facilitate/coordinate and verify that successful linkage to care occurred.Maintains effective communication with physicians, nursing staff, clients/patients, families and others related to discharge planning; coordinates with social services personnel to provide needed services.Contacts and directly engages patient's primary care physician and/or health care providers to support continuity of care and effective care transition.Interview, orient, train, precept, mentor and coach care management staff, and coordinate and direct the performance of care coordinators and social work staff performing discharge planning and assessment, including work assignment/schedule.Collaborate in the development of departmental policies and procedures, clinical practice guidelines and critical pathways for designated targeted diagnosis.Act as an educational resource and provide consultation regarding case management, discharge planning process, clinical documentation requirements and applicable federal, state, and local regulations; may identify benefits, implications, and limitations of home care.Responsibilities also include:Initiates discharge planning/ care management interventions upon presentation by assessing the patient's needs, interviewing patient/caregiver and reviewing the interdisciplinary plan of care- utilizing risk assessment and intervention guide.Ensures that the interdisciplinary care plan, discharge plan & care transition are consistent with the patient's clinical course, continuing care needs and covered services.Perform cause analysis assessment on re-admissions/re-visits within 7, 30 days etc. & implement measures to reduce risk.Documents in Electronic Medical Record, Care Management systems and databases, etc. per departmental standardsCoordinates, reinforces, and validates discharge teaching using teach back method. Validates patient/caregiver understanding of diagnosis, signs & symptoms, medication regimen, follow up care, etc. Validates discharge readiness.Performs & coordinates all activities required to ensure patient's appeal rights under the Discharge Appeals program. Issues required notices to patient/caregiver and procures necessary signatures on forms this includes ALOC, discharge notices, letters of denials and/or reinstatement within regulatory timeframes.Prepares & assures timely completion of regulatory/ institutional/ facility/ departmental/ organizational discharge, transfer, order, and referral forms (PRI, Screens, Ml IQ, 485, face to face encounter, etc.). Procures necessary signatures on forms. Validates discharge readiness.Conducts and documents follow up phone calls to discharged patients per departmental policies/procedures, Project RED, Transitions of Care, Bundle payments, and other performance improvement guidelines/initiatives etc.Facilitates care delivery across the continuum with effective and validated care transitions and linkage to follow up care. This includes collaboration with community-based resources and MCOs disease management program.Provides reports and necessary information for continuing care to the receiving unit care manager, social worker and next level of care providers (PCP, ambulatory practice, SNF, etc.)Collects data on variances from screening criteria. Performs data analysis to proactively identify opportunities to improve processes and promote leading practicesCommunicates to Risk Management all incidents, which are potentially compensable eventsActs as financial liaison- responds to third-party payer denials of payments. Appeals denials. Coordinates reconsideration/peer-to-peer review and appeal activity with Physicians, UR, Patients Accounts, Medical Records and Social Work etc.Actively participates in performance improvement projects.Completes and participates in performance evaluations within hospital guidelines.Employs a high degree of skill in all oral and written communications and personal interactions. Uses appropriate resources and methods to resolve conflicts.Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.Demonstrates active collaboration with other members of the health team to achieve the Care Management programmatic goals.Maintains absolute adherence to Hospital and departmental policies and practices regarding confidentiality and patient's rights.Demonstrates knowledge and support of the Hospital's mission and values.Maintains clinical competency and current knowledge of regulatory, payer requirements and payer methodology (e.g. Per Diem vs. DRG) to perform job responsibilities.Obtains & maintains required certifications to perform job responsibilities.Proficient with the application of medical necessity criteria(s) and clinical guidelines (i.e. InterQual, Milliman).Provide care management interventions in the: Emergency department, inpatient units, across the continuum of care including the outpatient areas, and collaboration with post-acute providers e.g. Home Care, and SNF.Special projects as required.As the need arises the functions of this position will change to meet the needs of the institution.Minimum Qualifications1. Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED); and2. A Baccalaureate degree in Nursing or related health field from an accredited college or university; and3. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA); and4. Two (2) years of experience as a Registered Professional Nurse.If you wish to apply for this position, please apply online by clicking the Apply Now button:NYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs