ER Case Manager/Rn - Case Management

Status: Full Time

Shift: 3p-3a with rotating weekends

Exempt: No

Other information:

1.Previous Experience Required

Previous work experience in direct patient care areas. Emergency services and/or utilization review/case management experience preferred.

2.Specialized or Technical Education Requirements

Registered Nurse currently licensed to practice in the State of Louisiana. Knowledge of Prospective Payment System, DRG's, and Peer Review Organizations preferred.

Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations.

ACM or CCM certification preferred.

3.Manual or Physical Skills

Basic Computer skills preferred.

4.Physical Effort Required

Strength: Sedentary Push: occasionally

Pull: occasionally Carry: occasionally

Lift: occasionally Sit: frequently

Stand: frequently Walk: frequently

Responsibilities:

Provides initial utilization review for emergency room, surgical, and direct admit patients

1.Screens Emergency Room admits, direct admits and transfers from other facilities to the ED to ensure medical criteria for admission is met.

2.Performs initial clinical review on patients being admitted, and documents reviews and pertinent findings based on nationally recognized clinical guidelines.

3.Reviews the surgical scheduling list to identify appropriate pre-authorization for level of care should patient be scheduled for acute hospitalization.

4.Communicates outcome of admission screens based on established criteria clinical guidelines for medical necessity to the Medical Staff as necessary.

5.Provides recommendations for alternative levels of care when appropriate, based on established clinical practice guidelines.

6.Reviews admission orders for all patients being admitted during shift.

7.Serves as an information resource regarding insurance benefits and coverage to patients, caregivers, hospital, and Medical Staff on patients being admitted.

8.Refers cases which do not meet established admission criteria to dept. Supervisor, Coordinator, Director, and/or Chief Medical Officer or Medical Director. Manager or physician advisor.

Provides "on-call" and "back-up" case management services

1.Serves as "on-call" Case Manager for the hospitals after normal business hours. Manages inter-facility transfers, direct admissions, and status changes during this time. Refers requests for post-discharge referrals to community agencies to the Social Worker II assigned to the ER when present.

2.In the absence of a Social Worker, assesses and documents patient's psychosocial and discharge planning needs and collaborates with the physician for further treatment and discharge/transfer planning.

3.In the absence of a Social Worker, makes appropriate referrals to discharge planning, continuum of care, abuse, neglect and/or exploitation with all necessary information to other agencies/resources to ensure continuity of care. Works to place PEC/CEC patients for psychiatric treatment needs.

4.Follows North Oaks Health System's Compliance Programs and Federal and State Regulatory guidelines.

5.Follows North Oaks Health System Infection Control guidelines and practices.

6.Follows North Oaks Health System guidelines and practices related to HIPAA.

DESCRIPTION OF DUTIES: (continued)

7.Other duties as deemed necessary and appropriate.