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Emergency Department Care Manager
2 months ago
The Emergency Department Care Manager plays a vital role in ensuring the efficient and effective care of patients in the emergency department. This position requires a strong understanding of clinical criteria and the ability to communicate effectively with physicians, nurses, and other healthcare professionals.
Key Responsibilities- Conduct patient assessments and admission clinical reviews to ensure appropriateness of setting and timely implementation of the plan of care.
- Perform reviews of anticipated admissions, placements in Observation status, and discharges using evidence-based criteria sets.
- Screen appropriateness of admission, including observation versus inpatient status, utilizing MCG and/or InterQual criteria.
- Initiate and maintain communication and collaboration with physicians and other members of the treatment team to develop, implement, and evaluate the plan of care for the patient.
- Provide education to providers and staff on documentation needs and opportunities to support the appropriate level of care and the treatment being provided.
- Initiate prior authorization process when indicated for post-ED referrals and services.
- Utilize financial and insurance resources of the patient to maximize the patient's healthcare benefit.
- Intervene with physicians and other healthcare providers regarding clinical and utilization issues to ensure optimal patient outcomes.
- Communicate with third-party payors and/or review organizations as necessary and provide information to both government and private payors in accordance with regulation and/or contract requirements.
- Escalate to physician advisor when unable to resolve discrepancies with the attending physician.
- Provide early identification and intervention of ED patients at risk for readmission.
- Manage high-utilization patients and work to find alternatives for care to frequent ED visits.
- Provide identification of patients for whom standard of care treatments could be safely rendered at home or other lower level of care setting.
- Plan for discharges from the ED for patients who do not require admission to include arranging for Home Health, DME, placement, and community resources as they relate to social determinants of health.
- Provide patient and family education and counseling about existing health problem-related care.
- Utilize high-risk screening criteria to make appropriate community and post-ED referrals.
- Anticipate barriers/variances to the delivery of care and intervene as necessary.
- Coordinate and facilitate patient progression throughout the continuum.
- Collaborate with all members of the interdisciplinary team to facilitate appropriate care coordination and care delivery.
- May assist with coordination of patient transfers to other inpatient facilities when indicated.
- Document all CM assessments and interventions in the medical record.
- Associate's Degree in Nursing required.
- Bachelor's Degree in nursing or healthcare-related field preferred.
- 3+ years of relevant clinical case/care management experience in the acute care setting required.
- RN License in state of employment or compact.
- Case Manager certification preferred.
