- Position Summary: Registered nurse provides clinical case management for a large BCBS HMO of Illinois medical group. Performs all inpatient utilization reviews using Milliman Care Guidelines. Assists with hospital discharge planning. Screens requested outpatient medical services. Case manages medical group members with complex, chronic medical problems as identified by BCBS HMO of Illinois. Assist with management of statistical data required by BCBS HMO of Illinois. Interacts with patients, physicians, clinics, other hospitals, skilled nursing facilities, home care agencies via phone, email, fax. Requires basic skills in computer navigation, keyboarding, Word, Excel. Familiarity of EPIC(electronic medical record), Allscipts(utilization review application), and Milliman Care Guidelines is helpful. Requires a Bachelor's Degree in Nursing and a minimun of 5 years nursing experience.
Required: Bachelors Degree
Preferred: Masters Degree
Required: 3-5 years of previous job-related experience
Preferred: 6-10 years of previous job-related experience
Minimum Experience Details: Recent clinical experience in medicine, surgery, critical care, telemetry, or ED is required. Recent Case management experience is preferred. Managerial Experience: N/A
Required: Current Registered Nurse License State of Illinois
Position Responsibilities: UTILIZATION REVIEW: Uses approved criteria for admission and continued stay reviews to ensure appropriate setting and timely implementation of plan of care. PATIENT OUTCOMES MANAGEMENT: Reviews pertinent clinical information to assess patient's response to treatment and care. CARE COORDINATION: Responsible for patient assessment of complex clinical discharge needs and establishment of an appropriate plan of care with multidisciplinary team. PROFESSIONAL DEVELOPMENT: Demonstrates leadership behaviors that enhance and support team functions.