ED RN Care Manager - Utilization Managment

CHRISTUS Health; Corpus Christi (TX); On-site; USD 65,000 - 95,000; Full time

Job summary

A healthcare provider in Corpus Christi is seeking an Emergency Department Care Manager to oversee patient care processes within the ED. The position demands expertise in clinical case management and coordination with interdisciplinary teams to optimize care pathways. Candidates should have a nursing or social work degree, along with at least 3 years of relevant experience. This full-time role operates overnight, fostering a collaborative environment to ensure best patient outcomes and efficient use of resources.

Qualifications

• Graduate of an accredited school of nursing (BSN preferred) or Master’s degree in Social Work (MSW) required.
• 3+ years of relevant clinical case/care management experience in the acute care setting required.
• Familiarity with evidence-based medical necessity criteria sets required.
• Proficiency with medical and managed care terminology.

Responsibilities

• Manage patients’ progression through appropriate levels of care.
• Conduct patient assessments and clinical reviews for timely plans.
• Educate medical staff on admission criteria.
• Identify patients suitable for home care when appropriate.
• Educate ED staff on medical necessity and criteria.
• Coordinate with physicians and treatment team on documentation.
• Initiate post-ED referrals and authorization when indicated.
• Coordinate care transitions across the continuum.

Skills

Clinical case management

Patient assessment

Care coordination

Documentation

Crisis intervention

Education

BSN or MSW

Tools

Prior authorization software

Job description

Summary

The Emergency Department (ED) Care Manager is responsible for establishing, coordinating, and maintaining the process to increase patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum for the ED. The Care Manager collaborates with the patient and/or family, multidisciplinary team, physicians, community partners, and payers to ensure the patient’s progress and level of care are appropriately determined. The Care Manager has well-developed knowledge and skill in patient status in the inpatient and outpatient settings and collaborates with other care managers, social workers, Patient Access, physicians, and administrative leadership in the ED to determine the appropriate level of care. The Care Manager also has a robust understanding of services and resources outside of the hospital that would be of benefit to the patient and initiates referrals as indicated. This work includes patient assessment and management, resource management, identifying patients appropriate for admission, observation or outpatient status, care facilitation, discharge planning with referrals to all levels of care, and other duties related to the defined population.

Responsibilities

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Uses approved criteria to conduct patient assessment and admission clinical review to ensure the appropriateness of setting and timely implementation of the plan of care.
• Performs review of anticipated admissions, placements in Observation status, and discharges using evidence-based criteria set for appropriate level of care assignment.
• Provides identification of patients for whom standard of care treatments could be safely rendered at home.
• Screens appropriateness of admission including observation versus inpatient status.
• Educates ED physicians and nurses about medical necessity and admission criteria.
• Collaborates with physicians and other members of the treatment team on documentation needs and opportunities.
• Utilizes high-risk screening criteria to make appropriate community and post-ED referrals.
• Initiates prior authorization process when indicated for post-ED referrals and services.
• Escalates to physician advisor when unable to resolve discrepancies with the attending physician.
• Manages high-use patients and works to find alternatives for care to frequent ED visits.
• Plans for discharges from the ED for patients who do not require admission to include arranging for Home Health, DME, placement, and community resources as they relate to social determinants of health.
• Provides patient and family education and counseling about existing health problem-related care.
• Anticipates barriers/variances to the delivery of care and intervenes as necessary.
• Intervenes with physicians and ancillary departments concerning clinical and utilization issues to ensure optimal patient outcomes.
• Coordinates and facilitates patient progression throughout the continuum.
• Collaborates with all members of the interdisciplinary team to facilitate appropriate care coordination and care delivery.
• Able to analyze clinical information and accurately apply clinical criteria.

Job Requirements

Education/Skills

• Graduate of an accredited school of nursing (BSN preferred) or Master’s degree in Social Work (MSW) required

Experience

• 3+ years of relevant clinical case/care management experience in the acute care setting required
• Familiarity with evidence-based medical necessity criteria sets required
• Competency in prior authorization functions and software, including the application of criteria and timelines required
• Proficiency in medical and managed care terminology required

Licenses, Registrations, or Certifications

• RN or LMSW in the state of employment is required
• Case Manager certification preferred
• BLS preferred

Work Schedule

7PM - 7AM

Work Type

Full Time