West Suburban Medical Center, LLC

For over 100 years, West Suburban Medical Center has supported generations of families in the Oak Park and surrounding areas. Our kind, caring hospital staff have a passion to heal and make a difference in our community. We understand that our employees are the heart of our facility. If you are looking for a family atmosphere, accompany committed to professional growth and a culture that embraces our five core values of Quality. Innovation. Service. Integrity. Transparency.

Job Summary:

The Case Manager (RN), as part of a multidisciplinary team, including physicians, and payers, ensures the patient’s progress in the acute episode of care through post discharge and is quality driven while being efficient and cost effective. This role works with the attending and consulting physicians to facilitate effective and efficient transition through the process of hospitalization; works collaboratively with all members of the multi-disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted. The incumbent seeks the expertise of social workers to resolve psychosocial patient care issues and to develop complex patient transition/discharge plan as needed. The incumbent interacts with patients, family members, healthcare professionals, community, and state agencies in this effort.

Essential Duties & Responsibilities:

• Performs an admission review that includes at a minimum the following: an assessment of patient status e.g., inpatient vs. observation; a determination of whether the patient’s condition meets medical necessity criteria for inpatient care of if significant discharge barriers exist.
• Validates pay source and physician orders if necessary.
• Collaborates with social work colleague to determine approach to discharge planning and which discipline is most appropriate to lead.
• Calls in review on all cases that require review of whose payer status has not changed. Notifies manager if reviews are incomplete or days are denied.
• Reassesses patient as clinically indicated or required by payer.
• Documents authorizations and case notes according to departmental policy.
• Presents concise, comprehensive review of assigned patients during rounding.
• Identifies concerns regarding quality and risks. Reports same to supervisor.
• Interacts with physicians regarding medical necessity, identification of appropriate discharge, disposition, reasonable alternatives or information necessary to support discharge planning.
• Participates in Quality Improvement (QI) activities, pilots, workgroups and other activities to improve departmental operations.

Essential Job Functions:

• Works in conjunction with physicians, nurses, inter disciplinary team and others to assess, plan and initiate patient plan of care and initiate patient plan of care
• Facilitates and coordinates details of actual discharge to appropriate agencies
• Conducts inpatient admission reviews for appropriateness of setting, admission status (IP/OP) and level of care (intensive care, general care)
• Using approved medical necessity criteria, conducts admission and continued stay review to ensure appropriateness of the setting and timely implementation of the plan of care, to monitor the patient’s progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality, efficient and cost effective
• Insures that all critical elements of the care and discharge plan have been communicated to multi-disciplinary team, patient and family including expediting teaching needs.
• Identifies, plans and facilitates strategies to reduce length of stay and inappropriate resource consumption, working in collaboration with attending and consulting physician

Preferred Qualifications

• Bachelors of Science in Nursing from an accredited institution.
• Previous experience with administering medical necessity criteria.
• Previous care management experience for patients with multiple chronic disease and acute illness.
• Accredited Case Manager (ACM) or Certified Case Manager (CCM).
• Bilingual skills in either English/Spanish.

Knowledge, Skills, Abilities and Other Characteristics

• Knowledge of managed care and impact on patient care priorities.
• Knowledge of managed care, Medicare and Medicaid.
• Knowledge of the admission review process with the ability to conduct patient status assessments.
• Excellent interpersonal skills with the ability to work with a culturally diverse patient population and collaboratively with physicians, nurses, therapy department members, social workers and insurance company representatives.
• Ability to adopt another’s point of view to facilitate patient centered goal setting.
• Ability to streamline workflows.
• Ability to make sound judgments.
• Ability to prioritize, plan, and organize projects and tasks.
• Ability to multi-task, manage multiple or competing priorities, and meet deadlines in a fast paced and stressful environment.
• Attention to detail.
• Basic Office Suite skills to include Outlook, Excel and Word.
• Strong initiative.

West Suburban Medical Center provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws