ED Clinical Care Coordinator (ED C3) - Care Navigation

Montage Health•Monterey, CA

21d

About The Position

The ED Clinical Care Coordinator (ED C3) is the Emergency Department’s clinical spoke of the Care Navigation Hub. The role provides early visibility into anticipated admissions to support proactive bed planning, ensures admissions are appropriately statused, and helps prevent unnecessary admissions. The coordinator monitors ED demand, boarding, patient progression, disposition, and barriers to timely care, working with physicians, nurses, the Hub, and interdisciplinary partners to arrange appropriate placement and care pathways. The position provides clinical guidance on inpatient admission, observation, outpatient treatment, discharge, and alternative levels of care. It supports appropriate utilization of hospital resources, patient-status decisions, peer review when appropriate, and identification of clinical and nonclinical needs that affect safe disposition. Discharge and transition planning begins at ED presentation when needs are anticipated, with coordination of referrals and resources for complex or high-risk patients. The coordinator continues Care Navigation activities for admitted patients boarding in the ED, identifies patient-specific placement needs, helps resolve barriers with inpatient teams and the Hub, and coordinates interfacility EMTALA transfers. The role also provides clinical direction to the ED C3a, delegates appropriate non-clinical coordination activities, and ensures continuity between the ED clinical plan and services coordinated by the C3a.

Requirements

State of California RN license required.
American Heart Association Healthcare Provider BLS required.
Must pass orientation and initial competency assessment before independent assignment of patients requiring the applicable skill, and complete and pass all annual competencies.
Demonstrated clinical experience in a hospital or Emergency Department setting.
Experience evaluating patient diagnoses, clinical conditions, treatment plans, and outcomes using established clinical, utilization, and regulatory criteria.
Experience assessing patient status and level of care, including inpatient, observation, and discharge considerations.
Experience collaborating with physicians, nurses, Case Management, Social Work, and other interdisciplinary teams to coordinate patient care and facilitate timely disposition.
Experience identifying and resolving barriers to admission, patient progression, discharge, transfer, and transition of care.
Experience communicating complex clinical and utilization information effectively to patients, families, physicians, interdisciplinary teams, and other stakeholders.
Experience managing multiple priorities in a fast-paced environment while maintaining organization, sound judgment, confidentiality, and professional relationships.

Nice To Haves

A minimum of five years of current acute care hospital experience is preferred.
Experience in acute care case management, utilization management, care coordination, or a related clinical role is preferred.
Experience applying knowledge of Medicare, Medi-Cal, commercial insurance, and applicable state and federal requirements related to patient status, reimbursement, and utilization of healthcare resources is preferred.
Experience coordinating or connecting patients with post-acute, community, behavioral health, and other healthcare resources is preferred.
Acute hospital case management experience.
Utilization Management experience.
Emergency Department clinical experience.
Knowledge of local healthcare and community resources.
Knowledge of Medicare, Medi-Cal, commercial insurance, and applicable state and federal healthcare requirements.
Bachelor’s degree in nursing preferred.

Responsibilities

Monitor ED demand, boarding volume, anticipated admissions, and barriers to patient progression as the ED clinical spoke of the Care Navigation Hub.
Work with the Care Navigation Hub to recommend appropriate bed placement and help prevent boarding in light of current capacity constraints.
Collaborate with ED physicians, charge nurses, and interdisciplinary staff to anticipate admissions, observation patients, discharges, and care needs.
Track ED flow and throughput, intervene or escalate to prevent avoidable delays, and facilitate timely and appropriate patient placement and disposition.
Partner with Ancillary services to identify and prevent inappropriate ED testing and facilitate treatment in the outpatient setting.
Update and confirm bed requests to ensure accurate patient information and appropriate placement based on clinical needs, patient attributes, and required resources.
Identify and escalate barriers to admission, transfer, placement, progression, and discharge.
Advise physicians on appropriate disposition, patient-status determination, and patients who may not meet inpatient admission criteria.
Educate and consult with medical staff regarding patient status, bed placement, payer requirements, and appropriate utilization of hospital resources.
Initiate the physician peer review process when appropriate.
Identify patients who may benefit from alternative treatment or referral pathways and determine appropriate clinical referrals or interdisciplinary resources.
Collaborate with physicians and interdisciplinary teams to ensure disposition decisions are clinically appropriate and aligned with patient needs.
Initiate discharge and transition planning at ED presentation when needs are anticipated.
Identify clinical, functional, social, equipment, medication, transportation, caregiver, and post-acute needs that may affect safe disposition.
Develop or facilitate clinical discharge plans with physicians, nursing, C3a, Social Work, and other interdisciplinary partners.
Direct the ED C3a or appropriate interdisciplinary resource to facilitate referrals and follow-up for patients needing additional services or resources.
Address or escalate barriers to safe or timely discharge.
Identify patients at increased risk for readmission, repeat ED utilization, care fragmentation, or poor transition outcomes.
Coordinate care planning for frequent ED utilizers and medically complex patients with the interdisciplinary team and established Care Navigation programs.
Identify barriers to ongoing care and determine appropriate clinical and community resources to address them.
Continue Care Navigation activities for admitted patients boarding in the ED, including identifying and escalating barriers to inpatient placement and progression.
Identify patient-specific placement needs, such as oxygen, sitter requirements, isolation, equipment, or specialty services, and coordinate with the Hub and inpatient teams to resolve placement barriers.
Coordinate interfacility EMTALA transfers with physicians, transfer centers, receiving facilities, and other stakeholders.
Escalate delays related to diagnostics, consultations, transportation, environmental services, physician decision-making, bed availability, or other barriers affecting patient flow.
Collaborate with inpatient Clinical Care Coordinators, Utilization Management, Social Work, physician advisors, and community partners.
Delegate or direct appropriate non-clinical coordination activities to the ED C3a based on the established clinical plan.
Provide clinical direction and clarification to the ED C3a regarding patient needs, appropriate referrals, and escalation of barriers.
Review unresolved barriers identified by the ED C3a and determine appropriate clinical or interdisciplinary intervention.
Ensure continuity between the ED clinical plan and services coordinated by the C3a.
Pass orientation and the initial competency assessment before independently assigning patients requiring the applicable skill, and complete and pass annual competencies.