Nurse Case Manager, RN (Inpatient Utilization) (Garden City, NY)

• Direct, coordinate, and oversee the care management and discharge planning for patients within a designated region or assigned group.
• Conduct medical necessity reviews for inpatient admissions using evidence-based criteria (MCG guidelines) to confirm appropriateness of care.
• Perform concurrent reviews to assess the need for continued hospitalization, ensuring extended stays are medically justified and properly documented.
• Collaborate with attending physicians, care managers, and the interdisciplinary team to develop and support timely discharge plans, ensuring care is delivered within the expected length of stay for specific medical conditions.
• Apply consistent use of MCG guidelines to verify medical necessity for admission and continued hospitalization.
• Identify anticipated discharge dates and work with the interdisciplinary team to coordinate appropriate post-hospital care, including necessary follow-up services.
• Utilize clinical judgment to assess underlying causes of hospitalization, implementing strategies to reduce the likelihood of readmission.
• Ensure adherence to evidence-based criteria, clinical guidelines, and standardized care management protocols while maintaining compliance with regulatory standards and addressing patient needs.
• Consult with clinical colleagues, supervisors, Medical Directors, and other departments to address barriers to discharge, presenting cases at collaborative rounds to gather multidisciplinary perspectives for optimal patient outcomes.
• Demonstrate accountability in problem-solving, decision-making, and time management while maintaining strong oral and written communication skills.
• Identify and escalate any quality of care issues through established reporting channels.
• Exhibit professionalism and adaptability, responding to the evolving regulatory environment and making effective use of time in all responsibilities.
• Stay current with HealthCare Partners policies, procedures, and guidelines, acting as a resource for staff members and participating in the development and implementation of policy updates as needed.
• Support HealthCare Partners’ mission and contribute to the continuous improvement of policies, procedures, and care delivery programs.
• Perform other related duties as required to fulfill departmental and organizational objectives.

• Proficient in the use and application of MCG Guidelines for medical necessity and utilization review.
• In-depth knowledge of NCQA, federal, state, and other regulatory requirements impacting healthcare delivery and case management.
• Strong verbal and written communication skills, with the ability to convey information clearly, concisely, and professionally.
• Proven ability to work collaboratively with interdisciplinary teams, patients, families, and external case managers to achieve optimal care outcomes.
• Exceptional organizational and time management skills, with the ability to manage multiple priorities in a fast-paced environment.
• Expertise in discharge planning, ensuring smooth transitions from inpatient care to appropriate post-hospital services.

• Active RN license in New York State (NYS) required.
• Bachelor of Science in Nursing (BSN) preferred.

• A minimum of 3-5 years of experience in a healthcare setting, preferably in an acute care environment.
• Prior experience in utilization management (UM) and case management/care coordination.
• Experience in educating patients and families on care plans and discharge procedures.

Department: Medical Management
This is a non-management position
This is a full time position