Requisition ID: 54490
Location: Presence St Mary Chicago
2233 West Division Street, Chicago, IL 60622 United States (US)
Daily Hours: 8
Standard Hours: 40
Employment Status: Full-time
Employment Type: Regular
The Case Manager Registered Nurse provides clinically-based case management to support the delivery of effective and efficient patient care. Oversees utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Develops and maintains a unique patient specific care management plan with mutually agreed upon goals in collaboration with the Primary Care Physician (PCP), patient/family and treatment team; identifies gaps in care and barriers to care.
Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents information in the current electronic system (such as MIDAS).
Validates admission and continuing stay criteria with third party payers as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.
Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.
Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge. Addresses actual and potential barriers to discharge.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all task and functions. Other duties may be assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Graduate of an accredited nursing program is required. Minimum three years of experience in acute care nursing required.
Bachelor's degree in Nursing preferred. Three years of experience as a Case Manager in an acute care setting preferred.
Ability to effectively negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in obtaining solutions to problems. Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
Experience with electronic medical records such as MIDAS preferred.
Certificates, Licenses, Registrations
Registered Nurse with a current Illinois License required.
Case Manager certification preferred.
Business Unit: Presence St Mary Hosp SMEMC
Department Name: UR Care Management SMEMC
Nearest Major Market: Chicago
Job Segment: Medical, Nursing, Manager, Patient Care, Registered Nurse, Healthcare, Management