Licenses and Certification
• Active/Current Illinois RN License

Experience and Skills
• Technical Experience: 3 years Clinical Nursing

Role Specific Responsibilities
• Performs initial screening and concurrent patient assessment related to appropriateness of the level of care/status (class), diagnosis, procedures performed and intervenes to expedite the patient’s plan of care.
• Utilizes and maintains competencies with Xsolis platform/tools for risk stratification of medical necessity/ level of care throughout patients’ hospitalization.
• Evaluates the social determinants of health (SDOH) for impact to the care transition.
• Collaboration with social work team to address social issues that affect a safe, effective discharge plan.
• Collaborates with the interdisciplinary team to assess, monitor, implement and evaluate patient care needs during the hospital stay in order to smoothly transition the patient to the next level of care.
• Identification of delays in throughput.
• Interventions to correct delays.
• Tracking of avoidable delays/days to identify patterns or trends that may require corrective actions.
• Collaborates with necessary staff and post-discharge care providers to assure a safe and effective discharge plan.
• Provides and documents discharge planning services in a professional, collaborative, and timely manner to optimize meeting patients' posthospital discharge care needs.
• Utilizes evidence-based practice standards to guide the evaluation of care, length of stay, medical necessity of services, and appropriate use of organizational and patient centered resources.
• Develops and maintains collaborative relationships with organizations in the community that facilitate provision of appropriate care during the hospital stay and facilitate efficient and effective planning for continued care for the patient.
• Facilitates care coordination conferences with patient and/or family support structure and healthcare team to foster decision making that promotes patient advocacy.
• Compiles and analyzes medical necessity denial data from three facilities to determine level of appeal needed, implements appeals, and performs follow up processes.
• Develops, coordinates, and presents focused education sessions for SIH personnel and medical staff related to medical necessity denials and other process issues.
• Researches and compiles regulatory information/data and provides written and oral reports to senior leadership and medical staff.
• Adapts to regulatory changes and develops improvement opportunities.
• Participates in the denial management process, including medical necessity review for Recovery Audit Contractor (RAC).
• Acts as the case management liaison for participation on the RAC teams.
• Prepares multi-level written appeals.
• Provides second level review for non-billable admissions and coordinates notification of confirmed cases to business office.
• Supports Service Excellence initiatives contributing to the organization becoming a top performer in quality care, patient safety and patient satisfaction strategies.
• Understands and applies techniques to support the provision of population based appropriate care utilizing the Joint Commission standards, Centers for Medicare, and Medicaid Services (CMS) regulations/requirements, among other evidence-based tools.
• Acts as an expert resource to the interdisciplinary healthcare team, physicians and other leaders: Participates in interdisciplinary team meetings in a collaborative manner resulting in achievement of best patient outcomes.
• Participates actively in departmental and hospital wide teams, committees, or other improvement.