RN-ED Case Manager

Case Management Social Services

Responsible for facilitating the patient's hospitalization from preadmission through discharge from the Emergency Department to the community or to an alternative level of care. Interfaces with physicians, nurses, social workers, and other healthcare team members to expedite medically appropriate cost-effective care.

Education: Required: Bachelor of Science in Nursing (BSN) or Master's degree in Nursing Licensure/Certification: Required: California Registered Nurse (RN) licensure Preferred: Certification in Case Management Experience: Required: Two (2) years of experience as a RN in an acute care or case management setting Reports To: Clinical Manager or Director Supervises: N/A Ages of Patients: Pediatric, Adolescent, Adult, Geriatric Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to collect and analyze data to evaluate the quality of necessary medical services and cost of care data and demonstrate cost savings, Exercises a high degree of initiative, judgment, and discretion, Knowledge and ability to use established criteria for medical necessity, including Interqual guidelines, Knowledge of notices of non-coverage/denial letters to patients including Medicare/CMRI, federal and state and guidelines, Knowledge of regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition, Knowledge of the various health care delivery systems and payer prior approval requirements, Self motivated, self starter, and able to organize efforts around helping clients have a positive experience, Strong clinical and critical thinking skills and ability to establish and carry out complex plans of care for key diagnoses

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations. 2. Performs pre-admission review of patients admitted from ED; performs inpatient admission review within 24 hours or first working day after admission and concurrent utilization review as necessary to assure payment authorization. 3. Acts as a resource to ED staff and physicians regarding appropriateness of admission, levels of care (including related documentation requirements and observation vs. inpatient requirements), quality of care concerns and criteria/guidelines/protocols utilized in care planning and resource utilization. 4. Gathers sufficient information from and communicates with all relevant sources to facilitate appropriate discharge from ED to appropriate level of care to assure it is done in an accurate, safe, timely and cost effective manner to prevent readmission and/or frequent visits to ED. 5. Assists in triaging calls from other acute care facilities requesting patient transfers to EMC; determines transfer appropriateness by reviewing requested documentation and Interqual level of care criteria and discussions as necessary with admitting physician, supervisors and/or EMC administrators and/or other EMC personnel. 6. Escalates to physician advisor when unable to resolve issues with the attending physician, according to policy and timeframes established. 7. Uses ED tracking system, medical record, and demographic information to identify patients needing CM intervention; identify patients with frequent ED visits; identify patient returning in 48 hours to ED 8. Coordinates patient transfer to the appropriate level of care. Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed. Communicates resulting decisions to patient/family, physicians and members of healthcare team. 9. Works with ED nurse to ensure evidence based order sets are initiated, when available. Collaborates with other members of the interdisciplinary team to ensure ED relevant evidence based standards of care are met. 10. Facilitates communication regarding the plan of care, promotes collaboration among all members of the healthcare team. 11. Identifies opportunities to improve care/service. Assists in development and implementation of care performance improvement plans based upon analysis of patterns and trends identified from data collection. 12. Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes. Modifies plan of care as patient/family needs change to accomplish goals established in the plan of care. Communicates plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. 13. Facilitates communication and translation of above stated information to inpatient Care Coordinators for patients who will be admitted to inpatient or observation. 14. Facilitates the initiation of diagnostic services, treatment planning, and therapeutic treatment while patient is present in the emergency department of admitted patients. Reviews all available assessment and treatment planning data provided by other members of the interdisciplinary team. 15. Documents all care management assessments and interventions. Inserts most current discharge planning documentation into medical record. 16. Demonstrates understanding of payer prior approval requirements and the various health care delivery systems and payer plan contracts. Communicates with third party payers and/or review organization as necessary and provides information to federal, state, and privates payers and/or review organizations so that determinations regarding benefits and coverage may be made. 17. Complies with regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition 18. Maintains internal and external resources available to meet patient's needs. Shares this information with peers and other members of the healthcare team. 19. Assess ED patients and identify options other than a cute hospital admission when appropriate: screen and refer to acute rehabilitation, long-term acute care hospitals, and nursing homes for admission directly from the ED; screen and refer patients to clinics after initial exam; screen and refer patients for whom treatments could be safely rendered at home with services (e.g., IV antibiotics, low molecular weight heparin injections, wound care, etc.) 20. Coordinates clinical and financial discharge planning needs as necessary so that a smooth transition from the acute outpatient care setting to the community setting is ensured and inappropriate readmission is averted 21. Refers to Social Work for complex psychosocial and discharge planning issues and ensure appropriate follow-up. Consults with other members of the interdisciplinary team (physical therapy, pharmacy, etc.) to provide safe discharge as appropriate. 22. Identifies potential opportunities for cost savings. Evaluate services provided, timeliness and costs; assists in action plan development and implementation as requested/appropriate. 23. Performs other duties as assigned.