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Registered Nurse Case Manager
2 months ago
Position Overview
The Registered Nurse Case Manager 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 care plans for patients, collaborating closely with the patient, their family, and healthcare providers.
- Facilitates the coordination of care and services for designated patients throughout their treatment journey, engaging with families, physicians, care teams, and insurance providers.
- Employs advanced nursing skills to enhance the delivery of care, incorporating assessment, planning, intervention, and evaluation within the nursing framework.
- Maintains up-to-date knowledge of community resources to ensure a seamless continuum of care for patients.
- Promotes and assesses the effective use of resources, leveraging clinical expertise and community service awareness to achieve optimal patient outcomes.
- Organizes and leads care discussions for patients with extended hospital stays or as necessary.
- Records any unusual incidents and patient relations concerns, referring them to appropriate departments such as risk management and quality assurance.
- Analyzes quality and utilization metrics, including admission and discharge criteria, readmission rates, and compliance with Medicare standards.
- Evaluates patient and family requirements 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 within the interdisciplinary care plan and relevant records.
- Informs patients of their Medicare discharge appeal rights within designated timeframes.
- Issues notifications regarding observation status when applicable.
- Distributes non-coverage notices as required.
- Consults with physicians regarding admission status and engages 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 ongoing hospital stays.
- Monitors and records avoidable days, recommending service or process modifications as needed.
- Ensures adherence to managed care agreements and length of stay objectives while upholding quality standards.
- Develops and instructs staff on clinical guidelines and protocols that align with industry standards to minimize length of stay and resource use while maintaining care quality.
- Oversees documentation of appropriate diagnoses for outpatient and observation services to meet medical necessity criteria.
- Responds to inquiries from patient financial services regarding appeal support.
- Handles 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 Statement:
Northwestern Medicine is an affirmative action/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.
