Manages the operation of Case Management to ensure appropriateness of admission, length of stay and use of resources to effectively meet all utilization criteria on a concurrent basis.

Must be an R.N. or B.S.N.  Five years experience in clinical nursing or discharge planning is required.

• Plans and organizes the daily operation of Case Management.
• Assists in the performance of admissions, concurrent and focused reviews using Severity of Illness/Intensity of Service standard in accordance with InterQual criteria.
• Assists in the maintenance of appropriate documentation.
• Assists in the performance of telephone reviews as requested to obtain pre-certification and continued stay certification with private carriers and/or review firms.
• Closely monitors assessments to ensure case managers are assessing and evaluating patients’ potential for home maintenance; develops discharge plan with involved caregivers.
• Assists with making referrals to related agencies.
• Provides information to social service/discharge planners to facilitate discharge-planning process.
• Participates in multidisciplinary care conferences with other departments.
• Serves as a resource person to physicians and hospital staff in the appropriate use of health care resources.
• Serves as a liaison with nursing and medical staff and community agencies to facilitate problem solving and to coordinate services.
• Assesses and develops plan within scheduled time frame utilizing software applications – Star Utilization Management module and InterQual criteria.
• Remains current on all regulations of federal Medicare, intermediary, Blue Cross, Illinois Public Aid, and other third-party carriers; establishes guidelines, policies, and procedures to ensure compliance with such regulations.  Interacts effectively with external agencies, resolving problems expeditiously.
• Takes responsibility for upgrading professional skills and knowledge.  Remains current on all regulations for state and federal guidelines in association with InterQual criteria and other review agencies.
• Prepares and completes reports; participates in special projects.

• Demonstrates clinical competency by providing direct patient care in a designated clinical area on a routine basis.
• Performs other duties as assigned.