Emergency Department Care Manager - Case Management
About The Position
The Emergency Department (ED) Care Manager establishes, coordinates, and maintains processes that support patient throughput to the most appropriate level of care and facilitate interdisciplinary care across the ED continuum. The Care Manager collaborates with patients and/or families, multidisciplinary teams, physicians, community partners, and payers to ensure patient progress and level-of-care decisions are appropriate. The role requires knowledge of patient status in inpatient and outpatient settings and collaboration with care managers, social workers, Patient Access, physicians, and ED administrative leadership to determine the appropriate level of care. The Care Manager also identifies beneficial services and resources outside the hospital and initiates referrals as indicated. Work includes patient assessment and management, resource management, identifying patients appropriate for admission, observation, or outpatient status, care facilitation, discharge planning and referrals, and other duties related to the defined population.
Requirements
- Graduate of an accredited school of nursing or a Master’s degree in Social Work (MSW).
- At least 3 years of relevant clinical case/care management experience in an acute care setting.
- Familiarity with evidence-based medical necessity criteria sets.
- Competency in prior authorization functions and software, including applying criteria and timelines.
- Proficiency in medical and managed care terminology.
- RN or LMSW license in the state of employment.
Nice To Haves
- BSN preferred for nursing graduates.
- Case Manager certification preferred.
- BLS preferred.
Responsibilities
- Meet expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
- Use approved criteria to assess patients and conduct admission clinical reviews to ensure the appropriate care setting and timely implementation of the plan of care.
- Review anticipated admissions, Observation placements, and discharges using evidence-based criteria to determine the appropriate level of care.
- Identify patients for whom standard-of-care treatments could be safely provided at home.
- Screen admission appropriateness, including observation versus inpatient status.
- Educate ED physicians and nurses about medical necessity and admission criteria.
- Collaborate with physicians and other treatment-team members on documentation needs and opportunities.
- Use high-risk screening criteria to make appropriate community and post-ED referrals.
- Initiate prior authorization for post-ED referrals and services when indicated.
- Escalate unresolved discrepancies with the attending physician to the physician advisor.
- Manage high-use patients and identify alternatives to frequent ED visits.
- Plan ED discharges for patients who do not require admission, including arranging Home Health, DME, placement, and community resources related to social determinants of health.
- Provide patients and families with education and counseling about care related to existing health problems.
- Anticipate barriers or variances in care delivery and intervene as necessary.
- Address clinical and utilization issues with physicians and ancillary departments to support optimal patient outcomes.
- Coordinate and facilitate patient progression throughout the continuum.
- Collaborate with all interdisciplinary team members to facilitate appropriate care coordination and delivery.
- Analyze clinical information and accurately apply clinical criteria.
