Nurse Case Manager I/II - ED

Minimum Education
Bachelor's Degree (BSN)

Minimum Work Experience
5 years of related experience. (Required)
ED and pediatric experience preferred. (Preferred)

Functional Accountabilities

Ensuring Appropriate Utilization of ED
1. Routinely screen patients for ambulatory sensitive diagnoses.
2. Take action to redirect patients to appropriate point of care.
3. Explore PCP designation and any related access issues.
4. Track high ED utilizers and implement targeted interventions.
5. Educate all members of the care team about appropriate ED utilization.

Care Coordination
1. Develop Case Management plan for patients identified through team referral or case finding.
2. Provide necessary handoff and follow up to transition care to the community.
3. Interface with family, payer, other care team members and post acute providers to achieve quality and timely care transitions.
4. Partner with Emergency Medicine Physicians and nursing staff to identify risk factors and patient specific conditions which may lead to additional ED visits.
5. Identify community resources to support the outpatient plan of care.

Utilization Management
1. Screen patients awaiting admission to ensure patient is in correct status (IP vs. Observation) using payer criteria set.
2. Serve as a resource to the ED for placing patients in appropriate status.
3. Escalate high risk cases appropriately.
4. Identify opportunities to impact ED Length of Stay.

Authorization
1. Function as the financial gatekeeper by ensuring appropriate authorizations are obtained for direct admissions from physician practices and other facilities.
2. Link families to Financial Information Center as needed.
3. Validate insurance coverage for inpatient and outpatient services.

Data Management
1. Routinely track Case Management interventions and outcome metrics.
2. Track and trend ED denials. Take steps to reduce denials.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification

1. Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

1. Demonstrate collaborative and respectful behavior
2. Partner with all team members to achieve goals
3. Receptive to others’ ideas and opinions

Performance Improvement/Problem-solving

1. Contribute to a positive work environment
2. Demonstrate flexibility and willingness to change
3. Identify opportunities to improve clinical and administrative processes
4. Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

1. Use resources efficiently
2. Search for less costly ways of doing things

Safety

1. Speak up when team members appear to exhibit unsafe behavior or performance
2. Continuously validate and verify information needed for decision making or documentation
3. Stop in the face of uncertainty and takes time to resolve the situation
4. Demonstrate accurate, clear and timely verbal and written communication
5. Actively promote safety for patients, families, visitors and co-workers
6. Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance