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Job Type:

Regular

Scheduled Hours:

30

Work Shift:

Day (United States of America)

30 HPW, 10-hr day shifts

Job Description:

Position Summary:

The Emergency Department Case Manager is responsible and accountable for patient trajectory by assisting the healthcare team in improved patient outcomes. The focus is to identify the most appropriate level of care while facilitating throughput. The ED Case Manager will assist in identifying patients appropriate for Admission, Observation, or other patient care status.

This role is structured around four major functions

• Utilization Management

• Care Coordination

• Discharge Planning

• Preventing Unnecessary Re-admissions

Each of these functions support the Care Transitions Department’s goals of 1) Improving patient satisfaction and patient outcomes, 2) Decreasing length of stay, 3) Decreasing unit cost, 4) reducing readmissions.

Functions and Responsibilities:

A. Utilization Management

• Performs review of anticipated admissions utilizing InterQual criteria to assess for appropriate level of care assignment.

• Certifies Medicare admissions and utilizes Code 44 when appropriate

• Serves as a resource to patients, physicians, administration and hospital employees regarding issues related to patient classification and reimbursement.

• Refers inappropriate observation or anticipated admission cases to the Physician Advisor.

• Provides real time interventions to prevent delays and ensure compliance and revenue integrity with health care regulations

• Functions as a liaison between physicians and Physician Advisors Identifies and collects data regarding resource utilization for physicians, management and administration for evaluation and process improvement.

B. Discharge Planning

• Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with other care givers, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver.

• Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to proper post-acute providers are initiated.

• Increases patient and family satisfaction with the discharge from the ED

• Prevents unnecessary admissions for social reasons

• Functions as a liaison between the DEM and community-based resources on an as-needed basis

• Provides assessment, information, referrals, and other resource assistance to patient/family as needed

• Facilitates treatment, admission, discharge, and/or transfer in collaboration with physician and primary nurse

• Identifies high-risk social situations and works collaboratively with Social Work to coordinate resources to promote follow-up care

• Communicates with the Care Transitions Department about incoming patients that have discharge planning needs

• Assesses, coordinates and refers cases of suspected/actual abuse, domestic violence, or neglect to appropriate agencies

• Obtains authorization for services for discharge as needed

• Arranges for community services prior to discharge to meet patient’s post-discharge needs with recognition and documentation of patient choice of service providers

• Identifies potential quality & risk management issues based on acceptable standards of practice and refers cases to the Manager, Care Transitions or directly to the Risk/Quality Manager in her absence to ensure quality of patient care and prompt identification of potential problems.

• Documents Care Transition notes briefly and concisely.

• Advocates for the patient/family with other health care professionals and community agencies as indicated to enable them to negotiate various social systems.

Qualifications:

Required

• State of MA Registered Nurse (RN)

• 3-5 years acute care nursing

• Two years of recent utilization management and discharge planning experience

Preferred:

• Bachelor’s degree in nursing or healthcare related field

• Three years of recent utilization management and discharge planning experience

• ED nursing and/or case management

Knowledge, Skills, and Abilities:

• Demonstrates expertise in the utilization management and discharge planning principles, methods, and tools and incorporates them into the daily operations of the organization.

• Possesses strong knowledge of DRGs, LOS, variance analysis, and discharge planning related to the utilization of health care resources.

• Demonstrates clinical expertise to effectively facilitate the evaluation of the level of care required.

• Develops and maintains strong collaborative, and supportive working relationships with peers, physicians, and other clinical professionals.

• Provides and receives feedback in a positive and constructive manner.

• Demonstrates excellent written, verbal, organizational and presentation skills.

• Possesses knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement.

• Ability to multitask and work in a fast-paced environment

FLSA Status:

Non-Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

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Equal Opportunity Employer/Veterans/Disabled