Case Manager RN - Ed

Independence Health System Careers•Greensburg, PA

7d•Hybrid

About The Position

This role involves managing patient care, coordinating transitions, and ensuring optimal health outcomes. The Case Manager RN will assess, plan, implement, and monitor patient care options, working collaboratively with patients, families, caregivers, and the healthcare team. A key focus is on managing transitions of care to reduce readmissions and improve health outcomes. The position requires strong clinical reasoning, critical-thinking skills, and the ability to act as a patient advocate. The role also involves understanding community resources and facilitating patient access to care. Additionally, the Case Manager RN will review clinical criteria for ED and direct admission patients to determine appropriate levels of care, assist patients and families navigating the healthcare system, and coordinate discharge planning. This includes making referrals, coordinating authorizations, and providing follow-through for complex cases. The role also involves utilizing utilization review criteria, collaborating with physicians, and managing denials. Professional development and adherence to ethical conduct are also emphasized.

Requirements

Graduated of an accredited nursing program.
Two (2) years recent healthcare/clinical experience, or recent clinical experience in an emergency department, case management, or utilization review position.
Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.
Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.
Knowledge of payor/insurance benefits
Functional Skills on PC and Related Software (Microsoft Office)
Knowledge of basic office equipment such as copier, fax machine, etc.
Ability to understand and react effectively in a fast-paced environment.
Must have flexibility/prioritization skills.
Current licensure to practice as a Registered Nurse in the State of Pennsylvania
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance

Nice To Haves

BSN
Case management experience
Case management certification

Responsibilities

Maintains professional and technical knowledge by attending education workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
Assures quality of care by adhering to therapeutic standards, measuring health outcomes against patient care goals and standards, making or recommending necessary adjustments, and following system/hospital and nursing division's philosophies and standards of care.
Protects patients and employees by adhering to infection-control policies and protocols.
Documents patient status recommendations, care coordination, and discharge planning by charting in patient records.
Maintains continuity among the multidisciplinary team by documenting and communicating actions, irregularities, and continuing needs.
Maintains patient confidence and protects operations by keeping information confidential.
Ensures safe and effective transitions of care through standard work that helps to promote positive health care outcomes for Excela Health patients.
Assesses, plans, implements, coordinates, and monitors and evaluates options for patients, their families, caregivers, and the health care team, including providers, to promote effective care coordination outcomes.
Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.
Provides crisis management for clients; makes linkages for interventions as appropriate.
Initiates care coordination strategies that are evidence-based and outcome focused.
Identifies patient care requirements by establishing personal rapport with patients and caregivers.
Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.
Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions.
Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel.
Demonstrates competencies of clinical reasoning and critical-thinking skills for managing complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally competent care.
Assures care coordination that takes into account patients' values, needs, preferences, and their choice to self-direct care.
Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
Effectively manages transitions involving comprehensive planning, targeted outreach, and the timely transfer of information between parties critical to the transition.
Facilitates the flow of care to expedite appropriate discharge and prevent readmissions.
Assumes the leadership role in achieving outcomes and making the health system work for the patient.
Brings access, understanding, and knowledge of the community and the resources to support management of chronic illness.
Resolves patient problems and needs by utilizing multidisciplinary team strategies.
Maintains a cooperative relationship among health care teams by communicating information, responding to requests, building rapport, and participating in team continuous quality improvement and problem-solving methods.
Contributes to team effort by accomplishing related results as needed.
Reviews clinical criteria of all ED / Direct Admission patients for appropriate patient status (i.e. inpatient, observation services, outpatient testing/treatment) based on medical necessity criteria.
Discusses recommendations for level of care with ED physician and attending physician.
Discusses options for care with patients, families, and physicians involved in their care.
Remotely monitors bed board (where applicable).
Assists patients and their families through the complex emergency room environment and/or the hospitalization process.
Provides emotional support to patients and their families/support system as needed.
Connects patients and their families/support system to community services as needed and appropriate.
Plans, coordinates, and implements discharge plans for ED and ED hold patients, including but not limited to, referrals to skilled nursing facilities, personal care homes, home health, DME, drug and alcohol treatment facilities, transportation, or community-based services.
Coordinates authorization for admitted patients and/or patients transferred from the ED.
Provides case management follow through for the Unit Based Case Manager on cases requiring follow-through after normal business hours.
Attends meetings as appropriate and meets regularly with supervisor to exchange pertinent information.
Participates in continuing education activities, remaining knowledgeable in area(s) of expertise.
Maintains a high level of ethical conduct regarding confidentiality, dual-relationships, and professional stature.
Maintains patient and program records in accordance with applicable standards and regulations, grant requirements, etc.
Applies InterQual level of care criteria for Severity of Illness/Intensity of Service Indicators for potential admissions and ED hold patients.
Makes referral to Physician Advisor for second level review for patients in the ED hold not meeting inpatient criteria.
Recognizes and progresses the plan of care when an alternative level of care is appropriate.
Collaborates with the attending physician and multidisciplinary healthcare team to facilitate the progression of the plan of care.
Is cognizant of payor requirements for all patients in assigned caseload.
Is responsible for understanding and communicating plan benefit limits/availability to patient or their representative in management of case as necessary.
Is responsible for accurate and timely documentation in recognized databases to support Clinical Resource Management and ED components for each patient in assigned caseload.
Initiates contact with the attending physician on cases that do not meet InterQual Level of Care SI/IS indicators in order to clarify plan of care.
Educates physicians and other members of the healthcare team on the application of InterQual Level of Care Criteria to support an acute level of care and provides alternatives to acute care as appropriate.
Notifies the unit-based case manager of all real or potential cases in which an adverse determination or complex psychosocial situation is anticipated.
Identifies and facilitates transition to the most appropriate alternate level of care.
Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements.
Recognizes the necessity of taking ownership of one’s own motivation, morale, and performance and professional development.
Strives for behavior consistent with being committed to Excela’s missions, vision, and values.