Job Summary

Responsible for identifying and addressing the health needs of the FHN community. Provides hospital case management/utilization review and discharge planning to assure that the patient progresses through the continuum of care and is discharged to the most appropriate environment.

Utilizes team approach to promote continuity of care, problem solving skills and nursing process to achieve optimal patient outcomes. Coordinate the integration of a multi-disciplinary approach to patient care. Coordinate the hospital activities concerned with case management and discharge planning.

Adhere to departmental goals, objectives, standards of performance, policies and procedures. Ensure compliance with quality patient care and regulatory compliance. Must possess strong communication and critical thinking skills, self-motivated and be able to work independently. Work collaboratively with members of the clinical team to achieve desired patient outcomes. Facilitate the provision of care services needed to meet the patient's needs in a timely manner.

Job Responsibilities

Utilization Review:

• Justify admissions and continued stays through external payer/insurance pre-certifications, and concurrent certifications.
• Determine appropriate levels of care for each patient.
• Minimize and inform patients of their financial responsibilities.
• Ensure compliance with payer rules and regulations.
• Consult with the Emergency Department for appropriate admissions.

Utilization Management:

• Coordinate the patient progression to other levels of care (ICU - general acute, Acute - Rehab, SNF - custodial (NH)
• Manage and intervene with clinical resource usage for best financial and patient care outcomes for patients and FHN.

Clinical Care Management

• Assess patient progress and continued compliance with acute care level criteria through daily record reviews and interaction with the clinical staff.
• Facilitate proactive care planning and management utilizing an Interdisciplinary Care Team approach, establishing documentation and outcomes throughout the stay.
• Identify and initiate referrals related to infections, risk management, and quality of care issues to appropriate professionals, including medical staff quality issues.
• Validate that all needs are addressed, referred, followed up on, and documented.
• Assist CDMP's with obtaining documentation of conditions, diagnoses, and procedures.

Discharge Planning

• Ensure initial assessments and other documentation is in the record in a compliant, complete and timely manner and offer options for identified needs. Educate patients of identified needs and referrals (social services, Assisted Care applications, Public Aid applications, etc).
• Educate patients to promote appropriate selection of discharge options. Evaluate both clinical and financial perspective.
• Coordinate with physician and patient to establish projected discharge date and plan during the early phase of care; oversee the implementation of this plan.
• Discuss discharge plan and date with the patient at each visit (daily). Issue follow up Important Message from Medicare and Detailed notice if Medicare patient requests an appeal. Communicate discharge plan and date with clinical team members ie. Nursing.
• For high risk patients or those that chose a discharge plan other than what was recommended, follow up with the patient post discharge.

Quality of Care

• Review for Core Measures in the records on a daily basis. Communicate with nursing on the floors and report issues to Quality.
• Other
• Functions independently, exercising flexibility and adaptability, utilizing time constructively and prioritizing/organizing assignments for maximum productivity. Monitors quality outcome indicators/utilization standards.
• Assists with the development of care guidelines and protocols.
• Promotes consideration of patient values and preferences as they relate to ethical issues and patient rights.
• Provides informal leadership and support to encourage optimum development and performance of each staff member and provides an atmosphere that is compatible with team building.
• Displays competency for the Resource Manager role as evidenced in the annual performance appraisal following the FHN PRIDE Standards.
• Weekly on call rotation. Holiday call rotation with social services.
• Attend and lead multidisciplinary case rounds Monday through Friday.

Requirements

Education:

• An Associate Registered Nurse (RN) Degree
• 2-5 years prior field-related and other job-related experience would be needed

Required Experience:

• Utilize nursing process and critical thinking skills into practice.

• Ability to assess, diagnose, plan implement, coordinate, monitor and evaluate to promote quality and cost effective outcomes.
• Proficient computer and phone skills
• Strong communication and negotiations skills to prevent denials.

Licensure/Certification/ Registration:

• Current IL RN license.

Populations Served:

While performing this job, the employee may care for patients in the following age groups.

• Adolescent: 13 to < 17 years

• Young Adult: 17 to < 30 years
• Middle Adult: 30 to < 60 years
• Older Adult: > 60 years
• Serves patients in areas other than patient care. No responsibility to treat or care for patients.

While performing this job, the employee does not care for patients in the following age groups.

• Neonate: < 30 days
• Infant: < 1 year
• Early Childhood: 1 year and < 5 years
• Late Childhood: 5 years and < 13 years