Discharge Preventionist Case Manager

$95,795 - $114,484/Yr

Stony Brook University - Stony Brook, NY

Full-time - Mid Level

Stony Brook, NY

Educational Services

About the position

The Discharge Preventionist Case Manager at Stony Brook Medicine is responsible for identifying hospitalized patients at high risk for readmission and coordinating their care to improve outcomes. This role requires strong clinical and communication skills to support patients and their caregivers throughout their hospital stay, ensuring they receive appropriate resources and follow-up care post-discharge.

Responsibilities

• Identify high-risk patients and intervene with the support of the medical team to improve outcomes.
• Monitor 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.
• Document the case management plan 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.
• Advocate on the patient's behalf to help ensure they receive appropriate care.
• 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.
• 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 interdisciplinary team regarding transition of care including Case Managers, Social Workers, Pharmacists, Medical staff, Nursing, Physical Therapist, etc.
• Actively participate 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.
• Adhere to all State and Federal requirements, RN license, JACHO, CMS, and DOH regulations.
• Maintain high level customer service.

Requirements

• Bachelor's degree with 3-5 years of Case Management experience.
• NY RN License.
• Acute hospital experience.
• Transitional care experience.
• Computer proficient in Electronic Medical Record applications.
• Demonstrate knowledge of discharge planning and length of stay.
• Courteous, professional, focused, and good listening skills.
• Weekend flexibility.
• Good customer service.

Nice-to-haves

• Master's degree.
• Bilingual.
• Certified in Case Management, Utilization Management, Quality, Risk, or MCG.
• Experience with post-acute care coordination, including acute rehab/skilled nursing.
• Home Care experience.
• Telehealth experience.

Benefits

• Generous leave policies
• Health plans
• State pension
• Location pay for UUP, CSEA & PEF full-time positions ($3400)
• Night shift differential ($15,000)
• Evening shift differential ($10,000)
• Inconvenience pay/supplemental shift differential ($575)