ED Case Manager (RN) at FirstHealth of the Carolinas – Pinehurst, North Carolina

ED Case Manager Job Summary

• Reviews each new patient record using criteria guidelines per policy for medical necessity and ensuring that patients are in the appropriate status/level of care. Includes initial review and continued stay review as requested by secondary payor.
• Refer recipients of Medicare and Medicaid who do not meet criteria to the Physician Advisor.
• If facilitated to Physician Advisor as the next step, follows through with their recommendation for Level of Care by obtaining order and providing Outpatient/Observation notices as required per policy.
• When Code 44 cannot be followed per regulatory requirements, the hospital, physician and patient are notified per regulations as outlined in the Utilization Management Plan.
• Provides Hospital Issued Letters of Non-Coverage per CMS regulations.
• Performs continued stay reviews per policy and submits clinicals to payers per protocol by responding to requests for additional information within same business day.
• Complete task as assigned. Offers assistance to peers when own assignment is completed.
• Track variance days/delays per policy.
• Reviews all denials, providing additional clinical as requested, arranges peer to peer as needed, updating Denials Management Specialist of progress in process thereby assisting in facilitating correct billing and payment.
• Collaborates with: admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of appropriate level of care in the electronic medical record and for billing accuracy.
• Assists discharge planning staff in clinical decision-making and priority setting to ensure an optimal length of stay
• Collaborates with nursing staff, discharge planners, ancillary staff and physicians when there is an educational need in regard to utilization review/management.

*On an occasional basis may have to perform the below job duties as a Discharge Planner in the ED:

• Facilitates coordination and development of comprehensive and individual plan of care in collaboration with patient, family and multidisciplinary team to include goals and interventions relative to patient needs and choice. Coordinates and Prioritizes discharges daily in a timely manner. Makes patient/family rounds maintaining communication with all members of healthcare team. Reviews all tasks daily for follow up of assignment.

• On a concurrent basis assesses appropriateness of discharge disposition and communicates any changes in plan/needs with appropriate resources. Develops, implements, and manages processes for referrals to Home Health, HME, SNF, and other agencies/facilities. Promotes a timely, cost-effective, efficient, and safe discharge plan to community services including long-term care, home health services, etc. Tracks avoidable days on all patients as indicated. Assists staff in clinical decision-making and priority setting to ensure an optimal length of stay. Collaborates with admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of efforts and activities.

• Utilizes approved departmental communication tools for documentation. Acts as Liaison for interdisciplinary communication and coordination of discharge plan. Initiates Guardianship/APS/CPS referrals when appropriate and communicates with all necessary disciplines and agencies. Serves as a liaison for the physician/nursing staff/ancillary departments to implement processing of the patient through the healthcare delivery system. Proactively identifies and resolves delays and obstacles to discharge. Identifies appropriate venue for care within the continuum. Promotes a quality care environment while maintaining fiscal responsibility for resource conservation by promoting multidisciplinary practices. Dispenses the second copy of "The Important Message to Medicare Recipients" timely and according to CMS regulations.

ED Case Manager Qualifications

• Bachelor’s Degree in Nursing with a minimum of 3 years nursing experience in medical/surgical, critical care and/or hospice, home health or public health required or Associate Degree in Nursing with a minimum of 4 years’ experience in medical/surgical, critical care and/or hospice, home health or public health required.
• Master Degree in Nursing or related field preferred.
• Case Management (ACM or CCM), MCG certification preferred.