RN, Case Manager Full-Time

1 month ago

Chicago, Illinois, United States Loretto Hospital Full time
Job Summary

The Case Manager assumes responsibility for assessing and directing the clinical management of patients in specific case groups for an episode of care. The Case Manager is responsible for developing and meeting desired patient care outcomes for his/her caseload based on assessment of patient care needs and on established clinical care patterns, within an appropriate length of stay and appropriate use of resources.

Key Responsibilities
  1. Conducts initial screening and assessment of patients on admission, including observations using pre-established Intensity of Service and Severity of Illness criteria. Determines diagnosis-related group (DRG) and appropriate length of stay (LOS) through the MCG program.
  2. In collaboration with physicians and other healthcare professionals, plans, organizes, directs, and evaluates the continuum of patient care. Evaluates interventions of physicians and other healthcare disciplines based on care pathways, severity of illness, and intensity of service criteria.
  3. Facilitates the patient's movement throughout the hospital system in cooperation with the clinical staff, other healthcare professionals, and the physician. Coordinates, negotiates, procures, and manages the plan of care to facilitate cost-effective quality of care and patient satisfaction.
  4. Conducts review of patient records according to established utilization review criteria to ensure appropriateness of hospitalization. Communicates with Medicare, Medicaid, and third-party payers to ensure coverage for services.
  5. Explores strategies to reduce the length of stay and resource consumption; implements and documents results. Identifies opportunities for system improvements.
  6. Prioritizes workload and focuses on problem cases; communicates with physician, nurses, department directors, and other healthcare providers, both internal and external.
  7. Documents on worksheets, assessment forms, and progress notes on a timely basis and as per policy.
  8. Facilitates appropriate referral consultation based on patient assessment, follow-up of required or delayed testing, care pathway, and results of physician intervention.
  9. Coordinates discharge planning, including assessment of discharge needs, resource availability, and communication of patient's needs among team members and families.
  10. Identifies and reports any quality, risk management, or utilization issues to the Director of Utilization Review/Case Management.
  11. Facilitates and coordinates patient care team conferences. Communicates utilization issues, discharge planning reviews, and variances of care.
  12. Completes all admission, discharge, and psychosocial assessments on a timely basis. Completes monthly statistical log to reflect case activity.
  13. Assists the Director of Utilization Review/Case Management in the investigation of over and underutilization cases, implementation of corrective measures, and chart review per medical staff request.
  14. Performs other related duties as assigned.
  15. Demonstrates working knowledge of payer requirements.
  16. Directs staff nurses to improvise documentation that relates to the patient's condition and orders/services obtained from the physician.
  17. In the absence of the case manager, the director serves in a leadership role by covering the department regarding staffing, issues, or concerns.
  18. Demonstrates awareness of regulatory requirements, including but not limited to, JCAHO, IDPH, CMS.
Compliance Responsibilities
  • Understands and adheres to Loretto Hospital's compliance standards as they appear in the Compliance Policy, Code of Conduct, and Conflict of Interest Policy.
  • Keeps abreast of all pertinent federal, state, and Hospital regulations, laws, and policies as they presently exist and as they change or are modified.
  • Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.
Job Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Licensed Nurse with current Illinois license; or
  • Bachelor's degree in a Healthcare-related field.
  • Minimum of two years' experience in Medical/Surgical, Psychiatry, and/or Critical Care.
  • At least one to two years' progressive experience in utilization management, discharge planning, or case management.
  • Strong communication skills, utilizes problem-solving process, acts as a team leader, demonstrates good work ethic, demonstrates good nursing assessment skills, maintains confidentiality, demonstrates flexibility, and analytical skills.
  • Has working knowledge of resources available in the community for the patient and families.
  • Has basic knowledge of criteria sets.
  • Demonstrates working knowledge of payer requirements.

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