General Summary of Position Responsibility:

This position is responsible for coordinating patient care across all levels and sites of care within CMMC. Coordinates services to provide care in optimal settings, and with optimal frequency and length of service. Coordinates the clinical and financial components of care management. Ensures payor requirements for information, authorizations and certifications are met. Provides a communication link between all involved in the case management plan.

Essential Job Functions:

1. Reviews insurance data collected for completeness. Facilitates communication of information to assure authorization and reimbursement/funding of patient care. Meets requirements and complies with contractual agreements. Ensures medical necessity and obtains authorization for continued care for patients. Coordinates appeal process for denied payments related to clinical/social problems.

2. Works with care team and family to implement case management plan. Provides communication link between all involved in case management plan. Assures coordination of care in collaboration with primary care provider. Collaborates regularly with payors, primary care physicians and other agencies to improve processes and systems related to case management. Assures communication with primary care physician, payor and/or other agencies upon discharge or transfer. Facilitates transition to next phase of care by serving as liaison between settings/clusters.

3. Reviews clinical and social data for every patient within 24 hours of admission. Identifies case management needs through review of record, participation in rounds, care conferences and clinician/family contact. Monitors patient/family progress in relationship to plan of care and expected outcomes. Assesses child/family case management needs.

4. Ensures use of clinical pathway and/or multidisciplinary plan of care. Refers families to resources available to meet identified needs. Advocates consideration of all options available to assure quality of care in the most cost-efficient manner. Facilitates processes to assure children are cared for in the most appropriate setting along the CMMC continuum. Initiates discharge plan at earliest time possible.

5. Coordinates services to assure smooth and timely transfer and/or discharge. Facilitates discharge and/or transfer to other care sites. Ensures referrals are made to appropriate services (WIC, schools) and coordinates associated activities. Serves as a resource to staff and families. Ensures assessment of on-going care needs is documented. Assures documentation of patient/family teaching and case management interventions in the patient record. Documents required clinical and financial information using appropriate systems.

6. Facilitates the evolution of critical pathways based on scientific findings supported by research literature. Collaborates with patient care team to develop critical pathways based on research findings. Tracks outcome performance data, identifies significant outcomes and assesses current clinical practice in relation to research based literature. Responds to nursing staffs and/or other patient team members request for evaluation of complex patients= progress along critical pathways, intervening and facilitating optimal patient outcomes.

7. Participates in the development of research proposals.

8. Identifies educational needs and coordinates with the patient care team. Communicates advanced knowledge and skills related to assigned patient population. Demonstrates clinical expertise in assigned patient population, role modeling application of clinical practice standards.

9. Contributes to staff and manager orientation related to outcomes. Practices sound fiscal management as evidenced by specific examples demonstrating decreased costs and participates in the annual budgeting process. Facilitates educational offering on cost based issues surrounding focused DRGs. Analyzes the cost factors related to patient outcomes and makes recommendations for change in clinical practice to facilitate a cost effective environment. Identifies marketing needs and coordinates with the patient care team.

10. Performs job functions adhering to service principles with customer service focus of innovation, service excellence and teamwork to provide the highest quality care and service to our patients, families, co-workers and others.

Knowledge, Skills and Abilities:

• Current RN licensure in the State of Ilinois required.
• Four to five years relevant clinical experience, broad knowledge of issues, trends, practices, and systems related to pediatric health care and case management acquired through clinical experience is essential. Experience working in partnership with health care professionals and support staff in clinical settings as necessary. Demonstrates ability to problem solve, support team work in a multidisciplinary setting and diplomacy is required. Must be flexible and adjust well to a changing environment. Computer literacy including word processing, business skills and excellent written and verbal communication skills necessary. Working knowledge of payor requirements, contracts and managed care.
• Demonstrates the ability to provide leadership to others in a collaborative and facilitative style within case management model. Bilingual preferred.

One year of prior Case Management experience or RN exp required.