Emergency Department Care Manager - Care Management

CHRISTUS Health•Corpus Christi, TX

13d

About The Position

The Emergency Department (ED) Care Manager establishes, coordinates, and maintains processes that increase patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum. The role collaborates with patients and/or families, multidisciplinary teams, physicians, community partners, and payers to ensure patient progress and level of care are appropriately determined. The Care Manager applies knowledge of patient status in inpatient and outpatient settings and works with other care managers, social workers, Patient Access, physicians, and ED administrative leadership to determine the appropriate level of care. The role also draws on knowledge of 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, and discharge planning with referrals to all levels of care.

Requirements

Graduate of an accredited school of nursing (BSN preferred) 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.
Case Manager certification.
BLS.

Responsibilities

Meet expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Use approved criteria to conduct patient assessments and admission clinical reviews, ensuring the appropriate setting and timely implementation of the plan of care.
Review anticipated admissions, observation placements, and discharges using evidence-based criteria for appropriate level-of-care assignment.
Identify patients for whom standard-of-care treatments could be safely rendered 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 seek 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.
Intervene with physicians and ancillary departments on clinical and utilization issues to support optimal patient outcomes.
Coordinate and facilitate patient progression throughout the continuum.
Collaborate with interdisciplinary team members to facilitate appropriate care coordination and delivery.
Analyze clinical information and accurately apply clinical criteria.