ED Clinical Care Coordinator (ED C3) - Care Navigation

Welcome to Montage Health’s application process!

Job Description

The ED Clinical Care Coordinator is the gatekeeper of the Emergency Department, providing the Hub early visibility of admissions to enable proactive bed planning, ensuring every admission is appropriately statused, and preventing unnecessary admissions.

Key Responsibilities

ED Flow, Throughput & Disposition

• Serves as the ED clinical spoke of the Care Navigation Hub, maintaining awareness of ED demand, boarding volume, anticipated admissions, and barriers to patient progression.
• Works with the Care Navigation Hub to prevent boarders by recommending appropriate bed placement to accommodate current capacity constraints
• Works proactively with ED physicians, charge nurses, and interdisciplinary staff to identify and anticipate potential admissions, observation patients, discharges, and anticipated care needs.
• Tracks patient flow and throughput in the ED, stepping in or escalating to prevent barriers from causing avoidable delays
• Collaborates with the Care Navigation Hub to facilitate timely and appropriate patient placement and disposition.
• Partners with Ancillary services to identify and prevent inappropriate ED testing and facilitate the treatments in the outpatient setting
• Updates and confirms bed requests to ensure accurate patient information and appropriate placement based on clinical needs, patient attributes, and required resources.
• Identifies and escalates barriers to admission, transfer, placement, progression, and discharge.

Admission, Observation & Utilization

• Serves as the clinical resource for appropriate patient disposition, collaborating with physicians regarding inpatient admission, observation, outpatient treatment pathways, discharge, and alternative levels of care.
• Discusses and advises physicians regarding patient status determination and patients who may not meet criteria for inpatient admission.
• Serves as a consultant and educator to medical staff regarding patient status, bed placement, payer requirements, and appropriate utilization of hospital resources.
• Initiates the physician peer review process when appropriate.
• Identifies patients who may benefit from alternative treatment or referral pathways and determines the appropriate clinical referral or interdisciplinary resource.
• Collaborates with physicians and interdisciplinary teams to ensure disposition decisions are clinically appropriate and aligned with patient needs.

Early Discharge & Transition Planning

• Initiates discharge and transition planning at ED presentation when needs are anticipated.
• Identifies clinical, functional, social, equipment, medication, transportation, caregiver, and post-acute needs that may impact safe disposition.
• Develops or facilitates the clinical discharge plan in collaboration with physicians, nursing, C3a, Social Work, and other interdisciplinary partners.
• Identifies patients requiring additional services or resources and directs the ED C3a or appropriate interdisciplinary resource to facilitate referrals and follow-up.
• Addresses or escalates barriers that may prevent a safe or timely discharge.

Complex & High-Risk Patients

• Identifies patients at increased risk for readmission, repeat ED utilization, care fragmentation, or poor transition outcomes.
• Coordinates care planning for frequent ED utilizers and medically complex patients in collaboration with the interdisciplinary team and established Care Navigation programs.
• Identifies barriers to ongoing care and determines appropriate clinical and community resources to address those barriers.
• Collaborates with the Care Navigation Hub and ED C3a to ensure identified needs are connected to appropriate resources and services.

Boarding, Transfers & Placement

• Continues Care Navigation activities for admitted patients boarding in the ED, including identification and escalation of barriers to inpatient placement and progression.
• Identifies patient-specific placement needs such as oxygen, sitter requirements, isolation, equipment, specialty services, or other clinical requirements that may affect bed placement.
• Coordinates with the Care Navigation Hub and inpatient teams to resolve barriers to placement.
• Coordinates interfacility EMTALA transfers in partnership with physicians, transfer centers, receiving facilities, and other stakeholders.
• Escalates delays related to diagnostics, consultations, transportation, environmental services, physician decision-making, bed availability, or other barriers affecting patient flow.

Care Navigation & C3A Partnership

• Functions as a clinical spoke of the Care Navigation Hub and collaborates with inpatient Clinical Care Coordinators, Utilization Management, Social Work, physician advisors, and community partners.
• Delegates or directs appropriate non-clinical coordination activities to the ED C3a based on the established clinical plan.
• Provides clinical direction and clarification to the ED C3a regarding patient needs, appropriate referrals, and escalation of barriers.
• Reviews unresolved barriers identified by the ED C3a and determines appropriate clinical or interdisciplinary intervention.
• Ensures continuity between the ED clinical plan and the services coordinated by the C3a.

Experience

• Minimum of five years of current acute care hospital experience preferred, with demonstrated clinical experience in a hospital or Emergency Department setting.
• Experience evaluating patient diagnoses, clinical conditions, treatment plans, and outcomes using established clinical, utilization, and regulatory criteria.
• Experience assessing patient status and level of care, including inpatient, observation, and discharge considerations.
• Experience in acute care case management, utilization management, care coordination, or a related clinical role preferred.
• Experience collaborating with physicians, nurses, Case Management, Social Work, and other interdisciplinary teams to coordinate patient care and facilitate timely disposition.
• Experience identifying and resolving barriers to admission, patient progression, discharge, transfer, and transition of care.
• Experience applying knowledge of Medicare, Medi-Cal, commercial insurance, and applicable state and federal requirements related to patient status, reimbursement, and utilization of healthcare resources preferred.
• Experience coordinating or connecting patients with post-acute, community, behavioral health, and other healthcare resources preferred.
• Experience communicating complex clinical and utilization information effectively to patients, families, physicians, interdisciplinary teams, and other stakeholders.
• Experience managing multiple priorities in a fast-paced environment while maintaining organization, sound judgment, confidentiality, and professional relationships.

Preferred Qualifications

• Acute hospital case management experience.
• Utilization Management experience.
• Emergency Department clinical experience.
• Knowledge of local healthcare and community resources.
• Knowledge of Medicare, Medi-Cal, commercial insurance, and applicable state and federal healthcare requirements.

Education

Bachelor’s degree in nursing preferred.

Must pass orientation and initial competency assessment prior to independent assignment of patients requiring the applicable skill, and must complete and pass all annual competencies.

Licensure/Certifications

State of California RN license required.

American Heart Association Healthcare Provider BLS required.

Equal Opportunity Employer

#LI-ES

Assigned Work Hours

0.9 FTE

Variable 12 hr Day shift, rotating weekends / holidays

Position Type

Regular

Pay Range (based on years of applicable experience):

$73.13

to

$97.81

The hours employees work determine when a shift differential is paid.

Hourly Evening Shift Differential: $5.50

Hourly Night Shift Differential: $8.00