Requisition ID: 61648
Location: Presence St Joseph Chicago
2900 North Lake Shore Drive, Chicago, IL 60657 United States (US)
Daily Hours: 8
Standard Hours: 40
Employment Status: Full-time
Employment Type: Regular
Than you for your interest in this position. We are conveiently located at 2900 N. Lake Shore Drive in Chicago IL. We are specifically looking for a Nurse with Substance Abuse or Behavioral Health experience.
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.
- Uses clinical knowledge to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient, family and health care team to intervene when progression is stalled or diverted.
- Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
- Participates in and follows through on interventions identified in care coordination and complex patient rounds.
- Identifies high risk patients and create a collaborative plan to address their unique needs.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. Other duties may be assigned.
Additional explanation of this position is as follows:
- Independently performs all Intake Services for the assigned department or unit. Provides clinical assessment and services to patients and families in the department and inpatient units. Coordinates and facilitates admissions to inpatient chemical dependency units and/or outpatient referrals as indicated.
- Performs Psychiatric Intake Assessments utilizing Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) and ASAM criteria/standards to determine clinical appropriateness and criteria for admission, transfer, or discharge. Formulates recommendations for disposition.
- Provides Case Management Services in the area of pre-authorization and pre-certification of benefits. Provides insurance companies with a Clinical Assessment. Determines third party payer benefits and develops alternative plans for those without benefits or out of network.
- Maintains relationships with other hospital programs and community agencies to increase referrals to the program. Responds promptly to the intake telephone line, provides crisis phone triage/crisis intervention, and refers clients to appropriate inpatient, outpatient or long term care programs and services.
- Demonstrates a thorough knowledge for the admitting and registration process, including the related computer programs.
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.
Experience with electronic medical records such as MIDAS preferred.
Certificates, Licenses, Registrations
Registered Nurse with a current Illinois License required.
Case Manager certification preferred.
Business Unit: Presence St Joseph Hsp Chicago
EOE of Minorities/Females/Vets/Disability