RN Care Manager Emergency Room - Per Diem Days

MLK Community Healthcare•Los Angeles, CA

10d

About The Position

The RN Care Manager supports physicians and the interdisciplinary team in coordinating patient care to improve clinical outcomes and patient satisfaction, manage costs, and provide timely, accurate information to payors. The role integrates utilization management, care progression, and care transitions. The Care Manager manages an assigned patient caseload, plans to meet patient needs, manages length of stay, and promotes efficient resource use. Work includes precertification and payor authorization, collaborative care management across the continuum, removing barriers to timely care and reimbursement, applying process-improvement methods, and coordinating communication with physicians. The Care Manager applies knowledge of RN scope of practice and applicable state and federal requirements, including CMS Conditions of Participation, EMTALA, the Patient Bill of Rights, AB1203, and regulations related to utilization review and discharge planning. In partnership with medical staff, the Care Manager uses scientific evidence, best practices, and relevant data to manage care throughout hospitalization. This includes admission, continued-stay, extended-stay, and discharge reviews across reimbursement categories to assess medical necessity, care quality, and efficient use of healthcare resources. The position supports the mission, Core Values, strategic plan, and quality and performance-improvement activities of Martin Luther King, Jr. Community Hospital. Responsibilities encompass patient assessment, discharge and transition planning, care coordination and implementation, evaluation of case-management plans and outcomes, communication and collaboration with care-team members and external partners, and professional practice within the nursing scope. The role is per diem and designated for days in the Emergency Room.

Requirements

Current California Nursing license.
Current Basic Life Support (BLS) certification.
One to three years of hospital or related experience; internal candidates with at least 18 months of acute-care case management or coordination experience may be considered in lieu of nursing clinical experience.
Ability to navigate and connect successfully with outside provider networks, including health plans, IPAs, and FQHCs.
Basic computer skills.
Emergency Department Care Managers must complete the annual Workplace Violence Prevention Program/certificate during initial training or orientation, no later than 90 days from hire or transfer.

Nice To Haves

Bachelor of Science degree in Nursing.
Bilingual language skills, preferably Spanish.
Certification in Case Management.

Responsibilities

Complete comprehensive assessments of patients’ physical, functional, psychosocial, cultural, spiritual, environmental, and financial needs, goals, and resources.
Complete and document timely clinical reviews based on medical necessity, clinical findings, hospital policy, and payer requirements.
Communicate with attending physicians about admission appropriateness, resource utilization, and documentation that does not support continued stay.
Assess readmission risk using established hospital criteria.
Develop safe, effective, and timely discharge and transition plans that account for medical necessity, payer requirements, patient condition, resources, and risk factors.
Engage patients and their families or support networks in transition planning and collaborate with the interdisciplinary team to adjust care plans as needed.
Advocate with payers and/or IPAs for effective care progression and transition plans.
Coordinate care progression and address patient and family needs; identify psychosocial and financial barriers and collaborate with or delegate to Clinical Social Work colleagues as appropriate.
Identify discharge needs and facilitate transfers to acute and post-acute settings, as well as home care and durable medical equipment arrangements.
Facilitate palliative or hospice care when needed.
Coordinate with physicians, nursing, and other care-team members to support timely care progression and desired outcomes.
Oversee discharge planning, facilitate safe transitions to community settings, and proactively resolve delays and obstacles to discharge.
Address system problems that impede diagnostic or treatment progress and seek appropriate consultation to expedite care and discharge.
Coordinate and monitor scheduling of tests and procedures and report results to other healthcare team members when appropriate.
Identify recurring problems and recommend strategies for resolution.
Develop and evaluate case-management plans and protocols with the interdisciplinary team.
Evaluate cost-effective care, including length of stay, DRG cost reporting, morbidity and mortality reports, and readmissions; use avoidable-day reporting to identify barriers to care progression.
Serve as a liaison among the care team, community providers, payers, and patients and families to support safe plans and smooth transitions.
Communicate with Patient Financial Services and Health Information Management as needed to confirm patient status or authorization for billing.
Collaborate with medical, nursing, and ancillary staff to remove barriers to efficient care delivery; review patient care, progress, and outcomes with attending physicians and consultants.
Define and manage deviations from the plan of care; participate in or facilitate patient-care conferences and family meetings.
Provide nursing and ancillary personnel with support and clinical expertise on patient-care issues; communicate with Nurse Managers and other Case Managers about individual cases and system problems.
Promptly report medical/legal issues to Risk Management and appropriate administrative parties.
Facilitate peer-to-peer discussions involving attending physicians, Case Management Consultants, and the Physician Advisor when payers require evaluation or justification of medical necessity.
Use conflict-resolution skills to resolve issues in a timely manner.
Assess personal knowledge and competencies, participate in departmental meetings, and share case-management knowledge.
Uphold patient dignity, privacy, and confidentiality; address concerns directly and constructively and demonstrate respect and care for internal and external customers.
Perform other related duties as assigned.