Nurse Case Manager, RN (Inpatient Utilization) - HealthCare Partners, MSO

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.  Interested in joining our successful Garden City Team?  We are currently seeking a Nurse Case Manager, Inpatient RN

Position Summary: The Inpatient Case Manager is responsible for ensuring the delivery of healthcare services with a focus on quality, cost-efficiency, and regulatory compliance. This role oversees care management and discharge planning, ensuring that patients receive medically necessary care while supporting timely and effective transitions from inpatient to post-hospital care.

Essential Position Functions/Responsibilities:

• 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.

Qualification Requirements:
Skills, Knowledge, Abilities

• 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.

Training/Education:

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

Experience:

• 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.

Base Compensation; $90,000 - $105,000
Bonus Incentive: Up to 5% of base salary


HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.