Utilization Case Manager Jobs in Elgin, IL (NOW HIRING)

Description

Full time Monday-Friday 8:00-4:30 and one weekend every 5 weeks and 1-2 holidays per year.

The Nurse Case Manager reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

• Assists in coordinating the patient's stay from admission through discharge. Assists to expedite medically appropriate, cost-effective care.  Helps to ensure patient is at the right level and site of care, and the patient moves along the continuum of care in a safe and timely manner.

Responsibilities:

• In collaboration with the patient/family, and members of the health care team, assesses, plans, implements, and evaluates the plan of care and the patient's response to treatment. 
• Continually proactive in collaborating and educating physicians and multidisciplinary team in appropriateness of admission, continued stay, utilization of resources and expected LOS. 
• Refers appropriate cases to patient financial services, peer review, patient relations, risk management.
• Collaborates with physicians and other health care team members to clarify admission status and plan of care. 
• Utilizes all available tools and resources to gain better and complete picture of clinical assessment of the patient: notifies physicians and staff of concerns/variations. 
• Relays pertinent information to appropriate care team members relative to admission, continuum of care and concerns related to discharge.
• Ensures that the interdisciplinary care plan and the discharge plan are comprehensive and consistent with the patient's clinical course, continuing care needs, and coordinated with covered services as available.
• Assesses and reassesses the patient for on-going care needs with knowledge of high-risk criteria and initiates referrals to the appropriate resources in a timely manner to progress toward the discharge plan.
• Participates in rounds and complex patient care conferences as indicated, identifying needs, barriers, and action plans.
• Performs utilization management activities of all inpatients and observation patients by applying approved criteria. Notify physician advisor of any outlier cases.
• Provides timely and thorough reviews to third party payers as requested or required. Experiences minimal denials based on lack of medical necessity.
• Has a good working knowledge base of available and diverse extended care providers for general population served. Asks co-workers for references for unfamiliar cases.
• Researches patient insurance plan in order to offer in-network providers of care and allow patient to make informed decisions.
• Partners with the nursing staff and physicians to convey accurate and timely information to post-acute care providers to encourage a smooth hand-off and create a seamless and safe discharge to the next continuum of care. 
• Partners with the care delivery team to identify proactively and coordinate any educational needs for the patient and family. 
• Ensures the patient is at the most appropriate level of care for the expressed severity of illness and level of services required. Applies National Guidelines and clear communication with physicians. 
• Collaborates with physicians and other health care team members to clarify admission status and plan of care.
• Coordinates appropriate bed placement for patients with Patient care services, collaborating on location, staffing etc.
• Queries the admitting physician for additional information as needed to meet medical necessity for admission or appropriate level of care. Refers cases to physician advisor for any outlier cases.
• Coordinates patient activity and flow or movement between levels of care. Identifies potential throughput barriers and acts proactively to inform and alert upper management of anticipated delays.
• Reviews clinical against Milliman criteria to help determine patient class and level of care needed. Confers with MD to discuss clinical and appropriate level of care when needed.

Qualifications

Qualifications:

Required

• Bachelors of Science in Nursing (required for hires after 01/01/2011)
• Registered Nurse in the state of Illinois
• One year of case management experience in an acute hospital setting 

Preferred

• Two years' experience in utilization review
• Case management certification
• Prior experience in case management or insurance setting.
• Bilingual 

Equal Opportunity

Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check.  Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. 

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility (if sign-on bonus offered for position): Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family. 

Qualifications:

Required

• Bachelors of Science in Nursing (required for hires after 01/01/2011)
• Registered Nurse in the state of Illinois
• One year of case management experience in an acute hospital setting 

Preferred

• Two years' experience in utilization review
• Case management certification
• Prior experience in case management or insurance setting.
• Bilingual