Emergency Department Care Manager - Case Management

CHRISTUS Health•Alexandria, LA

About The Position

The Emergency Department (ED) Care Manager establishes, coordinates, and maintains processes that improve patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the ED 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 uses 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. The work includes patient assessment and management, resource management, identifying patients appropriate for admission, observation, or outpatient status, care facilitation, discharge planning with referrals to all levels of care, 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).
Three or more 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

Bachelor of Science in Nursing (BSN) preferred.
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, ensuring an 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 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 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.
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 interdisciplinary team members to facilitate appropriate care coordination and delivery.
Analyze clinical information and accurately apply clinical criteria.