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Registered Nurse Case Manager
2 months ago
Position Overview
The Case Manager RN embodies the core mission, vision, and values of Northwestern Memorial Healthcare, adhering to the organization's ethical standards and compliance protocols while ensuring alignment with all relevant policies and regulatory requirements.
Key Responsibilities:
- Formulates and executes personalized treatment strategies for patients, collaborating closely with the patient, their family, and healthcare providers.
- Facilitates care coordination and service delivery for designated patients throughout their treatment journey, working in partnership with families, physicians, and the healthcare team.
- Employs advanced nursing skills to ensure comprehensive care delivery, which encompasses assessment, planning, intervention, and evaluation in accordance with nursing principles.
- Maintains up-to-date knowledge of community resources to enhance a continuum of effective patient services.
- Promotes and assesses the efficient use of resources, leveraging clinical expertise and community service awareness to lead the patient care team towards optimal outcomes.
- Organizes and leads care discussions for patients with extended hospital stays or as necessary.
- Records unusual incidents and patient relations concerns, referring them to appropriate departments such as risk management and quality assurance.
- Evaluates quality and utilization metrics, including admission and discharge criteria, readmission rates, and compliance with Medicare guidelines.
- Assesses the needs of patients and families for suitable discharge services.
- Acts as an advocate for patients and their families throughout the care continuum.
- Coordinates transitions to appropriate care levels, including skilled nursing, rehabilitation, long-term acute care, hospice, and home health services.
- Documents discharge planning in the interdisciplinary care plan and progress notes as applicable.
- Ensures timely delivery of Medicare discharge appeal rights and other relevant notifications.
- Consults with physicians regarding admission status and utilizes external advisory resources as needed.
- Stays informed on Medicare regulations pertaining to hospital and post-hospital services.
- Conducts medical record reviews to evaluate the appropriateness of admissions and continued stays.
- Monitors and documents avoidable days, recommending service or process adjustments as necessary.
- Ensures adherence to managed care agreements and length of stay targets while upholding care quality.
- Develops and provides education on clinical practice guidelines and protocols that align with industry standards to optimize resource utilization and care quality.
- Monitors documentation to ensure appropriate diagnoses for outpatient and observation services to meet medical necessity.
- Responds to inquiries from patient financial services regarding appeal assistance.
- Manages appeals for insurance denials related to medical necessity for both inpatient and outpatient services.
Qualifications:
Required:
- Registered Nursing license issued by the State of Illinois.
- Bachelor of Science in Nursing.
- A minimum of 5 years of relevant clinical experience.
Preferred:
- Master of Science in Nursing.
- Membership in a Professional Nursing Organization.
- Certification in Case Management (ACM).
Equal Opportunity Employer:
Northwestern Memorial Healthcare is committed to equal opportunity and affirmative action in employment, ensuring no discrimination based on age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation, or any other protected status.
