RN Care Manager Emergency Room - Full Time Nights-MLK Community Healthcare

RN Care Manager Emergency Room - Full Time Nights-MLK Community Healthcare Description Position Summary The purpose of the Case Manager position supports the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates the functions of utilization management, care progression and care transition. Specific functions within this role include: Facilitation of precertification and payor authorization processes Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement Application of process improvement methodologies in evaluating outcomes of care Coordinating communication with physicians. The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, The Patient Bill of Rights, AB1203 and other Federal or State regulatory agency requirements specific to Utilization Review and Discharge Planning. The Care Manager partners with the medical staff, utilizes scientific evidence for best practices, and relevant data to manage the care of the patient over the continuum of their hospitalization. These activities include admission, continued, extended and discharge reviews in all reimbursement categories to determine medical necessity, assure high quality of care and efficient utilization of available healthcare resources, facilities and services. This position requires the full understanding and active participation in fulfilling the Mission of Martin Luther King, Jr. Community Hospital. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support Martin Luther King, Jr. Community Hospital's strategic plan and the goals and direction of the quality and performance improvement process activities. ESSENTIAL DUTIES AND RESPONSIBILITIES Assessment Completes a comprehensive assessment to identify opportunities for intervention that are appropriate and realistic for the patient/family's psycho-social, cultural, spiritual, and physical plan of care. Assess the patient's healthcare needs and goals; specifically targeting the physical, functional, psychosocial, environmental and financial status. Completes and documents timely clinical reviews based on assessment of medical necessity and documented clinical findings in accordance with Hospital policy and payer requirements. Communicates with attending physician regarding appropriateness of patient admissions, resource utilization, and when documentation does not support continued stay. Assessments readmission risk based on established Hospital criteria. Planning Demonstrates an understanding of medical necessity and intensity of service, and incorporates payer requirements into the development of a safe, effective, and timely discharge plan. Demonstrates an understanding of the patient's clinical condition, social, and financial resources to determine the most appropriate care setting, practice standards for evaluation, treatment delivery options (Home, SAR, SNF, LTACH, Acute Rehabilitation, Assisted Living, Board/Care, Recuperative Care, Shelter), and resources required to support safe transition of care. Incorporates risk of readmission and socio-economic factors in the creation of a safe and individualized transition plan. Engages the patient and family/support network in developing the transition plan. Collaborates actively with the interdisciplinary team throughout the patient's stay to re-assess and adjust the plan for care progression and transition according to the patient's clinical condition. Advocates for the patient with the payer and/or IPA to ensure the most effective care progression and transition plan for the patient. Implementation Coordinates the progression of care to ensure that the ongoing needs of the patient and family are adequately addressed. a.Identifies psychosocial and financial barriers, (e.g. substance #J-18808-Ljbffr Anacalifornia