As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own. 

The Case Management RN is responsible for: the coordination of care of individual patients. Through the use of the nursing process, the patient care will be assessed, planned, implemented and evaluated with consideration to the appropriate use of resources. The Case Management RN will manage care with a focus on designated clinical, operational and financial outcomes for aggregate patient populations. In collaboration with the interdisciplinary team and a family-centered process, the Case Management RN will work to improve outcomes as measured by coordinating care to the appropriately timed discharge, reduced readmission rates and improved patient/family satisfaction. Using the Standards for Case Management as a framework, will incorporate ethical and legal tenets into the essential job functions.     

 1.Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria and third party information.  Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.  Documents all Case Management interventions in the Electronic Medical Record (EPIC).

 2.Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians.  Recommends alternative care sites where appropriate.

 3. Collaborates with third party payers to prevent denial of payment and proactively addresses issues contributing to a potential denial.  Intervenes to prevent the denial when possible.

4. .Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.

5. Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team.  Uses knowledge of usual length of stay to initiate a plan for discharge.

6. Uses clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes.  Communicates and coordinates with the patient/family and health care team to intervene when progression is stalled or diverted.  Addresses actual/potential barriers to discharge.

7. Completes the interventions necessary for discharges to home with self care, home with services or short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for discharge to home, placement, or transfer prior to the day of discharge.

8. Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.

9. Identifies high risk patients and creates a collaborative plan to address their unique needs.Conducts initial clinical reviews within 24 hours of patient admission. All reviews are to follow unit standards as per CM concurrent review guidelines.     

10. Monitors and facilitates correct patient class and accommodation codes via the EMR for every patient.

Qualifications:

• RN license required; BSN preferred
• At least 5 years of nursing experience

Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.