RN Case Manager

Works to enhance the effective utilization of organizational resources to assist the Medical Center in achieving its goals of high quality, cost-effective patient care and service, and for continuity of care across the continuum. Demonstrates compliance with external regulatory agency standards.

Conducts complete assessments, establishes appropriate plans, and initiates interventions within desired timeframes. Collaborates and negotiates effectively with patient, family, and team while striving to achieve patient and organizational goals with regard to patient’s care needs, choice and satisfaction when discharge planning/transitioning care. Utilizes patient/family strengths in the problem solving process, involving the patient/family and team in the decision making process beginning on admission and continuing throughout patient’s hospital stay.

Provides continuity of care and discharge planning services compliant with regulatory standards by providing coordinated relevant options and services based on assessed needs to ensure patient/family and healthcare team is informed and able to proceed with accountabilities in a timely manner. This includes participating in the communication process to facilitate a smooth transition for patient, family, and staff when patients are transferred.

Provides case management services related to various levels of health care, finances, housing, family discord, or illness adjustment, based department scope. This may include managing family dynamics and crisis situations in a timely and professional manner, using community resources effectively, and educating patient/family regarding access to and use of services.

Documents discharge planning interventions and utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria.

Communicates effectively with the healthcare team. Serves as an active member of the Outcome Facilitation Team/Multidisciplinary Team and works closely with medical staff, hospital departments and ancillary services in identification and resolution of barriers to discharge, expediting care delivery to avoid delays in timely service provision, and implementing and reporting utilization management (UM) activities.

Collaborates with managers, physicians, medical directors, advisory groups and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure accurate status and compliance with regulatory guidelines.

Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Provides clinical updates to payers and/or external review organizations, collects data, coordinates denial activity, supports UM activity, and manages avoidable delays. Delivers CMS regulatory notices within CMS established timeframes, as appropriate based on site guidelines.

Develops and maintains productive relationships with community-based agencies and networks by representing Aurora Health Care in a positive manner working collaboratively, internally and externally, to meet patient/family needs.

Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues and relevant regulatory requirements.

This position is a salaried day shift position. There is an occasional weekend and holiday commitment.

Licenses & Certifications

Registered Nurse license issued by the state in which the team member practices.

Degrees

Bachelor's Degree (or equivalent knowledge) in Nursing.

Required Functional Experience

Typically requires 3 years of experience in clinical nursing.

Knowledge, Skills & Abilities

Must have working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar productsKnowledge of the components of quality and acute patient care needs specifically related to the area/function in which care management will be performed.Demonstrates working knowledge of Utilization Review criteria as demonstrated by achieving 80% or greater on the annual InterRater Reliability (IRR) competency exam.Utilizes critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria. Excellent analytical and Interpersonal communication skills necessary to interact with families, patient, physicians and third party payers. Ability to manage conflict appropriately, seeking a win-win outcome by communicating issues in accordance with the Aurora Service commitments.Promotes effective professional relationships with physicians and other professionals in a direct and positive manner.Takes responsibility for self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives.