RN Case Manager - Medix : Job Details

The RN Care Manager plays a vital role in developing and overseeing personalized care plans for patients across various settings, including inpatient units, the Emergency Department, and other clinical areas. This role ensures patients receive the right level of care by balancing clinical quality with regulatory, financial, and utilization considerations. The RN Care Manager collaborates with physicians, social workers, nurses, and the interdisciplinary team while serving as a key resource for third-party providers regarding insurance and payment system guidelines. Key Responsibilities:

• Conduct comprehensive assessments to create and execute individualized care plans.
• Coordinate patient care activities to ensure alignment with appropriate care levels.
• Serve as a resource on insurance coverage, eligibility requirements, and payer guidelines.
• Use screening criteria such as InterQual and MCG to determine patient care needs.
• Facilitate safe and effective discharge planning, connecting patients to community resources.
• Communicate and collaborate effectively with interdisciplinary teams and external stakeholders.
• Maintain compliance with discharge planning and regulatory standards.

• Active NYS Registered Nurse (RN) license with a BS, BSN, or equivalent education.
• A minimum of 4 years of recent experience in acute medical-surgical, psychiatric, ED nursing, or case management.
• ACM (Accredited Case Manager) or CCM (Certified Case Manager) certification is required.
• Patient Review Instrument (PRI) certification is mandatory.
• Proficient knowledge of payer guidelines, reimbursement systems, and continuum of care requirements.
• Strong understanding of community resources and discharge planning regulations.
• Exceptional organizational and time management skills with the ability to multitask and prioritize.
• Effective negotiation and interpersonal communication skills for team collaboration.
• InterQual experience is required.