ED Case Manager (RN)

FirstHealth of the Carolinas, Inc.•Pinehurst, NC

11d•Onsite

About The Position

FirstHealth of the Carolinas is seeking an experienced Registered Nurse to work as an ED Case Manager in Pinehurst, North Carolina. This is an onsite, non-remote position. The role reviews patient records for medical necessity and appropriate status or level of care, conducts initial and continued-stay reviews, coordinates with payers and the Physician Advisor, and supports accurate billing and payment. The Case Manager collaborates with clinical and administrative departments and assists discharge-planning staff with clinical decisions and length-of-stay priorities. On an occasional basis, the role may also perform ED discharge-planning duties. These include coordinating individualized plans of care with patients, families, and the multidisciplinary team; arranging appropriate referrals and discharge resources; communicating across the care team; identifying and addressing discharge delays; and supporting safe, timely, cost-effective transitions to community services. The position also helps ensure documentation and notices comply with applicable CMS regulations and departmental policies.

Requirements

Current Registered Nurse qualification is indicated by the role and nursing degree requirements.
Bachelor’s Degree in Nursing and at least 3 years of nursing experience in medical/surgical, critical care, hospice, home health, or public health; or an Associate Degree in Nursing and at least 4 years of experience in those areas.

Nice To Haves

Master’s Degree in Nursing or a related field.
Case Management certification (ACM or CCM).
MCG certification.

Responsibilities

Review each new patient record using policy criteria to assess medical necessity and determine the appropriate patient status or level of care.
Perform initial and continued-stay reviews, including reviews requested by secondary payers.
Refer Medicare and Medicaid recipients who do not meet criteria to the Physician Advisor.
Follow up on Physician Advisor recommendations by obtaining orders and providing required Outpatient/Observation notices.
Notify the hospital, physician, and patient when Code 44 cannot be followed under regulatory requirements.
Provide Hospital Issued Letters of Non-Coverage in accordance with CMS regulations.
Submit clinical information to payers and respond to requests for additional information within the same business day.
Complete assigned tasks and assist peers when own assignments are complete.
Track variance days and delays in accordance with policy.
Review denials, provide additional clinical information as requested, arrange peer-to-peer reviews as needed, and update the Denials Management Specialist.
Collaborate with admitting, HIM, patient accounts, and patient care departments to support communication about level of care in the electronic medical record and billing accuracy.
Assist discharge-planning staff with clinical decision-making and priority setting to support an optimal length of stay.
Collaborate with nursing, discharge-planning, ancillary, and physician staff to address education needs related to utilization review and management.
On an occasional basis, coordinate individualized plans of care and daily discharge priorities with patients, families, and the multidisciplinary team.
Conduct patient and family rounds and maintain communication with healthcare team members; review assigned tasks daily for follow-up.
Assess discharge disposition and communicate changes in plans or needs to appropriate resources.
Develop, implement, and manage referral processes for Home Health, HME, SNF, and other agencies or facilities.
Promote timely, cost-effective, efficient, and safe discharge plans to community services, including long-term care and home health.
Track avoidable days as indicated and assist staff with clinical decision-making and length-of-stay priorities.
Use approved departmental communication tools for documentation and serve as a liaison for interdisciplinary communication and discharge-plan coordination.
Initiate Guardianship, APS, or CPS referrals when appropriate and communicate with necessary disciplines and agencies.
Help implement patient processing through the healthcare delivery system and proactively identify and resolve discharge delays and obstacles.
Identify appropriate care settings across the continuum and promote quality care while supporting responsible resource use.
Dispense the second copy of The Important Message to Medicare Recipients in a timely manner and according to CMS regulations.