Case Manager RN-Utilization Review Full-time Days
2 months ago
The Case Manager RN reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Develops and implements individualized treatment plans for patients, in collaboration with the patient, their family and provider.
- Coordinates 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.
- Utilizes advanced clinical skills to facilitate the provision of care which includes the assessment, planning, intervention and evaluation principles of the nursing process.
- Maintains current knowledge of resources available in the community to support a continuum of effective services for the patient.
- Promotes and evaluates 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.
- Plans and leads care conferences on patients with length of stays greater than 7 days or as needed.
- Documents unusual occurrences and patient relations issues; makes appropriate referrals to risk management, infection control and quality departments.
- Evaluates and analyzes quality/utilization cases, admission/discharge criteria, observation/1-day stays, readmits in 30 days, Medicare and diagnosis related criteria.
- Assesses patient and family needs for appropriate discharge services.
- Advocates for the patient and family throughout the entire episode of care.
- Coordinates transfer to appropriate level of care such as skilled care, rehabilitation, long term acute care, custodial, hospice and/or home health care.
- Documents discharge planning on the interdisciplinary plan of care, in progress notes and education record when applicable.
- Delivers notice of Medicare discharge appeal rights within the appropriate time frame.
- Delivers Observation letter notification when applicable.
- Distributes hospital issued non coverage notices.
- Consults with physicians in assigning admission level of care status and uses external physician advisory group as needed.
- Stays up-to-date on Medicare rules and regulations for hospital and post hospital services.
- Performs medical record review to assess for appropriateness of admissions and continued hospital stay.
- Monitors and documents avoidable days and recommends change in services or processes.
- Ensures compliance with managed care contracts and length of stay targets while maintaining quality of care.
- Develops and educates 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.
- Monitors documentation of an appropriate diagnosis for outpatient/observation testing to pass medical necessity.
- Responds to requests by patient financial services for appeal assistance.
- Appeals insurance denials for medical necessity for inpatient and outpatient services.
#INDNW
#LI-CC1
AA/EOE.
Qualifications
Required:
- Registered Nursing license issued by the State of Illinois.
- Bachelors of Science Nursing.
- 5 or more years of related clinical experience.
Preferred:
- Masters of Science Nursing.
- Membership in Professional Nursing Organization.
- Certification in Case Management (ACM).
Additional Information
Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.
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