Care Manager - Emergency Room
Company: Martin Luther King, Jr. Community Hospital
Posted on: September 12, 2022
If you are interested please apply online and send your resume
The purpose of the Case Manager I 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.
The Case Manager I is accountable for a designated patient caseload
and plans effectively to meet patient needs, manage the length of
stay, and promote efficient utilization of resources. Specific
functions within this role include:
- Facilitation of precertification and payor authorization
- 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
- 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
- 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.
- Assesses readmission risk based on established Hospital
- 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
- 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
- Advocates for the patient with the payer and/or IPA to ensure
the most effective care progression and transition plan for the
- Coordinates the progression of care to ensure that the ongoing
needs of the patient and family are adequately addressed.
- Identifies psychosocial and financial barriers, (e.g. substance
abuse, homelessness, unsafe or abusive living arrangement) and
collaborates with or delegates to Clinical Social Work
- Identifies discharge planning needs and facilitates transfers
to acute and post-acute venues.
- Demonstrates working knowledge of the clinical requirements,
individual payer networks and coverage, and impact of patient's
living environment and support network in creating a transition
- Identifies and facilitates home care and durable medical
equipment needs at the time of discharge.
- Facilitates palliative or hospice care when needed
- Works collaboratively and maintains active communication with
physicians, nursing and other members of the interdisciplinary care
team to ensure timely and effective care progression and
achievement of desired outcomes.
- Oversees discharge planning and facilitates safe transitions to
- Addresses/resolves system problems impeding diagnostic or
treatment progress. Proactively identifies and resolves delays and
obstacles to discharge.
- Seeks consultation from appropriate disciplines/departments as
required to expedite care and facilitate discharge.
- Coordinates and monitors scheduling of tests/procedures of
patients and reports results to other healthcare members when
appropriate. Identifies recurrent problems and recommends
strategies for resolution.
- Develops and evaluates case management plans and protocols in
collaboration with the interdisciplinary team.
- Evaluates actions taken to assure cost-effective care including
physician length of stay, diagnostic related groups cost reporting,
morbidity and mortality reports and monitoring of
- Utilizes avoidable day reporting tool to identify sources of
barriers to patients' progression of care.
- Serves as a liaison between members of the interdisciplinary
care team, community providers, payers, and patient/family to
ensure safe and effective plans and smooth transitions between
internal and external levels of care.
- Ensures consistent and timely communication with Patient
Financial Services and HIM as needed to confirm patient status
and/or authorization to support the billing process.
- Collaborates with medical staff, nursing staff, and ancillary
staff to eliminate barriers to efficient delivery of care.
- Collaborates with attending physicians and consultants to
review and discuss patient care, progress and identified outcomes.
Defines and manages deviations from the plan of care.
- Participates in and or facilitates patient care conferences and
- Provides support and clinical expertise for nursing/ancillary
personnel related to patient care issues.
- Maintains communication with Nurse Managers and other Case
Managers relative to individual patient care and/or system
- Assures prompt reporting of medical/legal issues to Risk
Management and appropriate Administrative parties.
- Facilitates peer to peer discussions between attending
physicians, Case Management Consultants, and Physician Advisor in
cases requiring evaluation and justification of medical necessity
for admission by the payer.
- Utilizes advanced conflict resolution skills as necessary to
ensure timely resolution of issues.
- Within the nursing scope of practice, the care manager
continuously assesses self-knowledge and competencies to assure job
- Actively participates in departmental meetings and shares
knowledge related to the practice of case management
- Demonstrates understanding of Medicare Conditions of
Participation as related to discharge planning, patient/family
engagement, and communication of financial responsibility.
- Maintains respect for the dignity of every person by addressing
issues and concerns with workers directly, with a positive
problem-solving approach, and the observance of the right to
patient privacy and confidentiality.
- Demonstrates concern, respect, and caring for all customers,
both internal and external, regardless of their diagnosis or
- Maintains positive interpersonal relations.
- Performs other related job duties as assigned.
- Bachelor of Science degree in nursing preferred
- Associates in Nursing required
- Minimum of one (1) to three (3) years of hospital inpatient or
related experience required.
- Able to navigate and connect successfully with outside provider
networks (Health Plans, IPA's, and FQHC's).
- Current California Nursing license
- Certification in Case Management preferred.
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish)
- Basic computer skills
- Current Basic Life Support (BLS) Required
Keywords: Martin Luther King, Jr. Community Hospital, Downey , Care Manager - Emergency Room, Executive , Downey, California
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