Case Manager RN-Case Management Full Time Days

4 weeks ago

Lake Forest Illinois, United States Northwestern Memorial Healthcare Full time
Job Summary

We are seeking a skilled RN Case Manager to join our team at Northwestern Memorial Healthcare. As a RN Case Manager, you will play a critical role in coordinating patient care and services to ensure optimal clinical and resource outcomes.

Key Responsibilities
  • Develop and implement individualized treatment plans for patients in collaboration with the patient, family, and provider.
  • Coordinate care and services for assigned patients for an episode of illness or treatment in collaboration with the patient, family, physician, patient care team, and payers.
  • Utilize advanced clinical skills to facilitate the provision of care, including assessment, planning, intervention, and evaluation principles of the nursing process.
  • Maintain current knowledge of resources available in the community to support a continuum of effective services for the patient.
  • Promote and evaluate the effective utilization of resources using current clinical knowledge, awareness of community services, and assuming a leadership role with the patient care team to achieve optimal clinical and resource outcomes.
  • Plan and lead care conferences on patients with length of stays greater than 7 days or as needed.
  • Document unusual occurrences and patient relations issues; make appropriate referrals to risk management, infection control, and quality departments.
  • Evaluate and analyze quality/utilization cases, admission/discharge criteria, observation/1-day stays, readmits in 30 days, Medicare, and diagnosis-related criteria.
  • Assess patient and family needs for appropriate discharge services.
  • Advocate for the patient and family throughout the entire episode of care.
  • Coordinate transfer to appropriate level of care, such as skilled care, rehabilitation, long-term acute care, custodial, hospice, and/or home health care.
  • Document discharge planning on the interdisciplinary plan of care, in progress notes, and education record when applicable.
  • Deliver notice of Medicare discharge appeal rights within the appropriate time frame.
  • Deliver Observation letter notification when applicable.
  • Distribute hospital-issued non-coverage notices.
  • Consult with physicians in assigning admission level of care status and use external physician advisory group as needed.
  • Stay up-to-date on Medicare rules and regulations for hospital and post-hospital services.
  • Perform medical record review to assess for appropriateness of admissions and continued hospital stay.
  • Monitor and document avoidable days and recommend change in services or processes.
  • Ensure compliance with managed care contracts and length of stay targets while maintaining quality of care.
  • Develop and educate staff on clinical practice guidelines/standing orders/protocols that complement industry standards to reduce length of stay and resource consumption while maintaining quality of care.
  • Monitor documentation of an appropriate diagnosis for outpatient/observation testing to pass medical necessity.
  • Respond to requests by patient financial services for appeal assistance.
  • Appeal insurance denials for medical necessity for inpatient and outpatient services.

AA/EOE.

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