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Registered Nurse Case Manager
2 months ago
At Northwestern Memorial Healthcare, we believe that every interaction with our patients is crucial in fostering a supportive and positive environment. Our commitment to a patient-centered approach distinguishes us as a frontrunner in the healthcare sector. As a vital member of our team, you will have the chance to contribute to our mission of enhancing healthcare quality, regardless of your role within the Northwestern Memorial Healthcare network.
Position Summary:
The Registered Nurse Case Manager embodies the mission, vision, and values of Northwestern Memorial Healthcare, adheres to the organization's ethical standards, and complies with all relevant policies, procedures, and regulatory requirements.
Key Responsibilities:
- Designs and executes personalized care plans for patients, collaborating closely with the patient, their family, and healthcare providers.
- Facilitates care coordination and services for assigned patients throughout their treatment journey, working alongside the patient, family, physician, care team, and insurance providers.
- Employs advanced clinical expertise to ensure comprehensive care delivery, encompassing assessment, planning, intervention, and evaluation within the nursing framework.
- Maintains up-to-date knowledge of community resources to support a seamless continuum of care for patients.
- Promotes and assesses the effective use of resources, leveraging clinical knowledge and community service awareness while leading the patient care team to achieve optimal outcomes.
- Organizes and leads care discussions for patients with extended hospital stays or as necessary.
- Documents any unusual incidents and patient relations concerns; makes appropriate referrals to risk management and quality assurance departments.
- Evaluates and reviews quality and utilization cases, including admission and discharge criteria, readmissions, and compliance with Medicare standards.
- Assesses the needs of patients and families for suitable discharge services.
- Acts as an advocate for patients and families throughout their care experience.
- Coordinates transitions to appropriate levels of care, including skilled nursing, rehabilitation, long-term acute care, hospice, and home health services.
- Records discharge planning in the interdisciplinary care plan and relevant documentation.
- Ensures timely delivery of Medicare discharge appeal rights notifications.
- Issues Observation letter notifications when applicable.
- Distributes hospital-issued non-coverage notices.
- Consults with physicians regarding admission level of care status and utilizes external advisory groups as necessary.
- Stays informed on Medicare regulations affecting hospital and post-hospital services.
- Conducts medical record reviews to evaluate the appropriateness of admissions and continued hospital stays.
- Monitors and documents avoidable days, recommending service or process changes as needed.
- Ensures adherence to managed care agreements and length of stay targets while upholding care quality.
- Develops and educates staff on clinical guidelines and protocols that align with industry standards to optimize resource use and maintain care quality.
- Monitors documentation for appropriate diagnoses to meet medical necessity for outpatient and observation services.
- 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).
Northwestern Memorial Healthcare is an equal opportunity employer and does not discriminate in hiring or employment based on age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation, or any other protected status.
