Care Manager - Readmission Specialist

Job Description - Care Manager - Readmission Specialist (2502561)

Care Manager - Readmission Specialist

At Stony Brook Medicine the Care Manager – Readmission Specialist must have both hospital and transitional care experience. The Care Manager – Readmission Specialist identifies hospitalized patients who may be at a high risk for readmission. The RN following these patients must have good clinical and communication skills to address the needs of the patient and caregiver throughout their hospital stay.

Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

Duties of a Care Manager - Readmission Specialist may include the following but are not limited to:

• Identify high-risk patients and intervene with the support of the medical team to improve outcomes.
• Monitors and coordinate an interdisciplinary plan of care with the patient and their support team.
• Participate in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided to the patients.
• Documents the case management plans such as clinical needs, barriers, utilization of resources via assessments and/or progress notes.
• Help connect the patient with appropriate resources, facilities, and providers.
• Communicate with multidisciplinary patient care team and patients/families.
• Run reports and identify patients at a high risk for readmission.
• Advocating on the patient’s behalf to help ensure they receive appropriate care.
• Works to identify any social determinants of health issues, address them, document them, and look for available services.
• Help patients understand their medical conditions, treatment plans, and the importance of following medical recommendations.
• Follow patients telephonically post-discharge and assist with barriers to care.
• Prior experience with Care Management or Utilization Management.
• Understand levels of care including Inpatient, Observation, ED and Outpatient.
• Understand the importance of readmission prevention and LOS reduction.
• Knowledge of high-risk readmission criteria.
• Understand insurance coverage and authorization.
• Effectively work with an interdisciplinary team regarding transition of care including Case Managers, Social Workers, Pharmacists, Medical staff, Nursing, Physical Therapist, etc.
• Active participation in rounds.
• Gather and document all necessary encounters with the patient and/or patients’ family.
• Track and trend data with analysis of information.
• Actively involved in performance improvement activities including program development and improvement, data collection and analysis.
• Adheres to all State and Federal requirements, RN license, JACHO, CMS and DOH regulations.
• Maintain high level customer service.
• All other duties assigned as needed.

• Bachelor’s degree with 3-5 years CM experience.
• Acute hospital experience.
• Transitional experience.
• Experience with post-acute care coordination, including acute rehab/skilled nursing.
• Computer proficient in Electronic Medical Record applications.
• Demonstrate knowledge of discharge planning and length of stay.
• Courteous, professional, focus and good listening skills.
• Good Customer Service.

• Bilingual.
• Certified in Case Management, UM, Quality, Risk or MCG.
• Home Care experience.

Resume/CV should be included with the online application.

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…