Nurse Case Manager, Inpatient UM RN

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?

Position Summary: The Inpatient Case Manager is responsible for coordinating high-quality, cost-effective, and medically appropriate care for hospitalized patients, ensuring compliance with regulatory standards, evidence-based guidelines, and organizational policies.

This role focuses on concurrent review, utilization management, and discharge planning to support safe, timely, and effective transitions from inpatient settings to post-acute levels of care. The Inpatient Case Manager collaborates closely with physicians, nurses, social workers, and interdisciplinary care teams to optimize patient outcomes, reduce avoidable readmissions, and ensure appropriate utilization of healthcare resources.

Essential Position Functions/Responsibilities:

• Provides oversight and coordination of inpatient care management and discharge planning for assigned patient populations or geographic regions.
• Performs admission and concurrent review of inpatient stays using evidence-based criteria (MCG guidelines) to determine medical necessity, appropriateness of care, and level of service.
• Monitors patient progress throughout hospitalization to assess continued stay criteria and ensures documentation supports medical necessity and regulatory compliance.
• Identifies anticipated discharge dates early in the admission process and proactively coordinates discharge planning with the interdisciplinary care team.
• Collaborates with attending physicians, specialists, nurses, social workers, and ancillary providers to develop safe, timely, and effective discharge plans.
• Ensures patients transition to the appropriate level of care, including home with services, skilled nursing facilities (SNF), rehabilitation, behavioral health, or other post-acute settings as clinically indicated.
• Applies clinical judgment to identify root causes of hospitalization and implements interventions aimed at reducing preventable readmissions and avoidable utilization.
• Coordinates care transitions by ensuring timely referrals, follow-up appointments, medication reconciliation, and post-discharge support services.
• Conducts ongoing case review to ensure alignment with clinical guidelines, standardized protocols, and payer/regulatory requirements.
• Identifies and addresses barriers to discharge, including clinical, psychosocial, financial, and system-level challenges.
• Facilitates interdisciplinary rounds and care conferences to support shared decision-making and alignment on patient care plans.
• Escalates complex clinical, utilization, or quality concerns to Medical Directors, leadership, or appropriate departments as needed.
• Documents all utilization review, case management activities, and discharge planning interventions accurately, thoroughly, and in a timely manner.
• Ensures compliance with NCQA standards, Medicare/Medicaid regulations, state requirements, and organizational policies.
• Participates in quality improvement initiatives focused on reducing length of stay, readmissions, and inappropriate utilization.
• Serves as a resource to clinical staff regarding utilization management processes, discharge planning protocols, and regulatory requirements.
• Maintains professionalism and adaptability in a fast-paced, high-acuity inpatient environment with evolving priorities.
• Participates in policy and workflow updates to support continuous improvement of care management operations.
• Supports organizational mission, values, and strategic goals through high-quality clinical and operational performance.
• Performs other duties as assigned in support of departmental and organizational objectives.

Qualification Requirements:
Skills, Knowledge, Abilities

• Strong proficiency in MCG Guidelines and utilization review processes for inpatient care.
• In-depth understanding of NCQA standards, Medicare/Medicaid requirements, and other applicable federal and state healthcare regulations.
• Strong clinical assessment skills with ability to evaluate medical necessity and level-of-care appropriateness.
• Excellent verbal and written communication skills with ability to document clearly, accurately, and professionally.
• Strong collaboration skills with ability to work effectively within interdisciplinary teams and external care partners.
• Exceptional organizational, prioritization, and time management skills in a high-volume acute care setting.
• Strong critical thinking, clinical judgment, and problem-solving abilities.
• Knowledge of discharge planning principles, transitions of care, and post-acute care resources.
• Ability to identify barriers to care and implement effective care coordination strategies.
• Proficiency in electronic medical records (EMR) and utilization management systems preferred.
• Ability to manage competing priorities and work independently with minimal supervision.

Training/Education:

• Active Registered Nurse (RN) license in New York State (NYS) required.
• Bachelor of Science in Nursing (BSN) preferred.
• Training in utilization management, case management, or discharge planning strongly preferred.
• Knowledge of evidence-based clinical guidelines and care coordination frameworks preferred.

Experience:

• Minimum of 3–5 years of clinical experience in an acute care hospital setting required.
• Prior experience in utilization management (UM), inpatient case management, or care coordination strongly preferred.
• Demonstrated experience in discharge planning and transitions of care.
• Experience working with interdisciplinary care teams in a hospital or managed care environment.
• Experience providing patient and family education related to care plans, post-discharge needs, and health management.

Base Compensation; $95,000 - $105,000 annually

Equal Employment Opportunity Statement:
HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Job Disclaimer:
The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.