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Case Manager-RN

Company: Presence Health
Location: Carol Stream
Posted on: June 4, 2019

Job Description:

Requisition ID: 64710

Ministry: Presence St Joseph Hosp Elgin

Location: Presence St Joseph Elgin

Location Address:
77 North Airlite Street, Elgin, IL 60123-4912 United States (US)

Department: 20200035 UR Care Management PSJH

Daily Hours: 12
Standard Hours: 40
Employment Status: Full-time
Employment Type: Regular
Shift: Day
FLSA: E

SUMMARY

The Case Manager - Registered Nurse provides clinically-based case management to support the delivery of effective and efficient patient care. Oversees utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Develops and maintains a unique patient specific care management plan with mutually agreed upon goals in collaboration with the Primary Care Physician (PCP), patient/family and treatment team; identifies gaps in care and barriers to care.

  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents information in the current electronic system (such as MIDAS).

  • Validates admission and continuing stay criteria with third party payers as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.

  • Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.

  • Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge. Addresses actual and potential barriers to discharge.

    QUALIFICATIONS

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

    Education and/or Experience

    Graduate of an accredited nursing program is required. Minimum three years of experience in acute care nursing required.

    Bachelor's degree in Nursing preferred. Three years of experience as a Case Manager in an acute care setting preferred.

    Ability to effectively negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in obtaining solutions to problems. Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.

    Computer Skills

    Experience with electronic medical records such as MIDAS preferred.

    Certificates, Licenses, Registrations

    Registered Nurse with a current Illinois License required.

    Case Manager certification preferred.

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  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.\\xa0 Documents information in the current electronic system (such as MIDAS).\\n
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  • Validates admission and continuing stay criteria with third party payers as well as Primary Care and Attending Physicians.\\xa0 Recommends alternative care sites where appropriate.\\xa0\\n
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  • Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.\\xa0 Intervenes to prevent the denial where possible. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.\\n
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    QUALIFICATIONS \\n\\n
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    Graduate of an accredited nursing program is required. Minimum three years of experience in acute care nursing required. \\n\\n
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    Bachelor\\u2019s degree in Nursing preferred. Three years of experience as a Case Manager in an acute care setting preferred. \\n\\n
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    Ability to effectively negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in obtaining solutions to problems. Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge. \\n\\n
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    Computer Skills \\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 \\n\\n
    Experience with electronic medical records such as MIDAS preferred. \\n\\n
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    Certificates, Licenses, Registrations \\n\\n
    Registered Nurse with a current Illinois License required. \\n\\n
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    Case Manager certification preferred. \\n \\n\\n
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    SUMMARY \\\\n\\\\n
    The Case Manager \\\\u2013 Registered Nurse provides clinically-based case management to support the delivery of effective and efficient patient care. Oversees utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. \\\\n\\\\n
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  • Develops and maintains a unique patient specific care management plan with mutually agreed upon goals in collaboration with the Primary Care Physician (PCP), patient/family and treatment team; identifies gaps in care and barriers to care.\\\\n
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  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.\\\\xa0 Documents information in the current electronic system (such as MIDAS).\\\\n
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  • Validates admission and continuing stay criteria with third party payers as well as Primary Care and Attending Physicians.\\\\xa0 Recommends alternative care sites where appropriate.\\\\xa0\\\\n
    \\\\xa0 \\\\n \\\\n
  • Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.\\\\xa0 Intervenes to prevent the denial where possible. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.\\\\n
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  • Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge. Addresses actual and potential barriers to discharge. \\\\n \\\\n\\\\n
    \\\\xa0 \\\\n\\\\n
    QUALIFICATIONS \\\\n\\\\n
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    Graduate of an accredited nursing program is required. Minimum three years of experience in acute care nursing required. \\\\n\\\\n
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    Bachelor\\\\u2019s degree in Nursing preferred. Three years of experience as a Case Manager in an acute care setting preferred. \\\\n\\\\n
    \\\\xa0 \\\\n\\\\n
    Ability to effectively negotiate with internal and external providers of patient care services. Must have analytical abilities to assist in obtaining solutions to problems. Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge. \\\\n\\\\n
    \\\\xa0\\\\xa0 \\\\n\\\\n
    Computer Skills \\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0\\\\xa0 \\\\n\\\\n
    Experience with electronic medical records such as MIDAS preferred. \\\\n\\\\n
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    Certificates, Licenses, Registrations \\\\n\\\\n
    Registered Nurse with a current Illinois License required. \\\\n\\\\n
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    Business Unit: Presence St Joseph Hosp Elgin

    Job Function: Nursing

    COMPANY OVERVIEW:

    EOE of Minorities/Females/Vets/Disability

    Job Segment: Nursing, Medical, Patient Care, Case Manager, Registered Nurse, Healthcare

    Associated topics: ambulatory, cardiothoracic, coronary, intensive, intensive care, nurse rn, recovery, registed, tcu, unit

Keywords: Presence Health, Carol Stream , Case Manager-RN, Executive , Carol Stream, Illinois

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