• 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.

Minimum Qualifications

• Registered Professional Nurse in the State of Illinois
• Three (3) years of experience as a Registered Professional Nurse in any of the following steps: inpatient care, home care, ED, or patient centered medical home

• Bachelor 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 or English/Polish

• 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

• Competitive Salary
• Paid Time Off
• Health, Vision & Dental Insurance
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Short & Long Term Disability
• 401 (K) with company match
• Life Insurance