Job Description:

• PURPOSE OF THE JOB:

To ensure collaboration among multiple parties; the patient, family and the multi-disciplinary team (internal and external stakeholders), which may include the payer in an effort to facilitate and coordinate services specific to the patients' needs during a stay in the Emergency Room and post-discharge needs or as an admission to the hospital. All case manager activities will be client-centric, performed in a proactive manner, require on-going assessment of needs, evaluation of resources, knowledge of associated costs and education as indicated. The case manager is responsible for presenting options in an unbiased fashion to all involved parties and in compliance with HIPAA. Empowerment of the patient or healthcare proxy is expected and maintained so an informed decision regarding continued care needs can be made. Advocacy and education are at the heart of all activities with the basic goal focused on providing best clinical outcomes possible for the patient through evidenced based practice.

• ESSENTIAL FUNCTIONS

• Utilization Management: Serve as a resource for Emergency Department (ED) staff on level of care placement based on utilization criteria and methodologies (i.e. XSOLIS) as well as medical necessity.

• Discharge Planning: Arrange discharge services from the ED for patients that do not required admission to the hospital. This may include Home Care, Infusion, Skilled Nursing, Long Term Care, Durable Medical Equipment (DME), Oxygen Therapy (O2) or referrals to other outpatient services and agencies as appropriate to meet the patient needs. Assessment and evaluation of the patient needs will be conducted by reviewing current and prior functioning, psycho-social dynamics, and identification of support system. In collaboration with psychiatric services the ED case manager will coordinate and facilitate the transfer of ED patients to psychiatric services to include facilitating the completion of the 201 and 302 forms. The discharge plan is developed in collaboration with the multi-disciplinary team which may include the payer and will include active input from the patient and/or family. Identification of barriers must be considered in order to facilitate a smooth and successful transition to the next level of care. The case manager will address issues with prior plan of care, specifically with regards to readmissions.

• Implementation and facilitation of care activities: The case manager will act in a proactive manner addressing real and potential issues with the development and implementation of the plan of care. Documentation of the case manager's activities and discussions should be outlined in the patient's medical record. This might include but is not limited to reaching out to external stakeholders such as the primary care provider and requesting assistance with the development of the plan of care. The purpose would be to overcome any identified barriers to care with the goal being to achieve a successful outcome for the patient. Additionally, the case manager should be verifying benefits and securing authorizations from the payer as indicated and documentation should include facilitation of necessary community resources as needed. Lastly, advocacy is an important aspect in the case manager's role as he/she must take into consideration the patient's ability to safely maintain themselves in the community or when the patient's capacity is in question. The case manager needs to ensure the patient or healthcare proxy has the ability to fully understand the options of care being presented so an informed decision can be made. Also, this could include acting as a mediator between physicians/consultants and families when conflict arises or a change in status occurs that may put up road blocks to a successful transition to the next phase of care.

• Data Collection: Case Manager will participate in the collection of information regarding quality improvement activities, risk management issues and reporting this information through appropriate committee structure.

• Behavioral Expectations: Exhibit consistent professional conduct in interaction with patients/families, medical staff, payers and peers while also respecting HIPAA requirements. Takes ownership for errors and takes immediate corrective action when indicated.

Job Qualifications:

• QUALIFICATIONS

When considering candidates the manager will take into consideration the overall department skill set and candidate knowledge and experience for this role.

• Education:
• Registered Nurse: must have a current license in Pennsylvania from the Commonwealth of Pennsylvania, Department of State Bureau of Professional and Occupational Affairs. Bachelor degree preferred.

• Experience:
• Registered Nurse: a minimum of three or more years of acute care clinical nursing. Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, home care or case management. ED Case Management experience preferred.

• Other Skills:
  • General Skills All Disciplines: Excellent verbal and written communication skills. Strong organizational and prioritizing skills. Thorough understanding of managed care systems and utilization review criteria. Knowledge of community resources. Demonstrated leadership abilities. Experience in the use of information systems. Must be able to manage and perform well under stress.
  • Certification and Licensure:
    • Prefer Certification in Case Management (CCM) which reflects advanced education, practice and work experience.
    • Prefer a Bachelor degree in Nursing.