ER Care Manager RN: Care Coordination & Transitions

Mlk-Community-Healthcare-1; California (MO); On-site; USD 75,000 - 105,000; Full time

Job summary

MLK Community Healthcare in Los Angeles, CA seeks a Case Manager to support physicians and the interdisciplinary team, focusing on quality outcomes, patient satisfaction, and cost management. The role coordinates utilization management, care progression and discharge planning to ensure timely and appropriate care.

You will handle caseload management, precertification, payer communications, and collaboration with clinicians.

Qualifications

• Bachelor of Science degree in nursing preferred.
• Minimum of 1–3 years hospital or related experience.
• Internals with at least 18 months acute care case management experience will be considered in lieu of nursing clinical experience.
• Able to navigate and connect successfully with outside provider networks (Health Plans, IPA’s, and FQHC’s).
• Bilingual language skills preferred (Spanish).
• Current Basic Life Support (BLS).
• Certification in Case Management preferred.

Responsibilities

• Completes a comprehensive assessment to identify opportunities for intervention that are appropriate and realistic for the patient/family’s psycho-social, cultural, spiritual, and physical plan of care.
• Assess the patient’s healthcare needs and goals; specifically targeting the physical, functional, psychosocial, environmental and financial status.
• Completes and documents timely clinical reviews based on assessment of medical necessity and documented clinical findings in accordance with Hospital policy and payer requirements.
• Communicates with attending physician regarding appropriateness of patient admissions, resource utilization, and when documentation does not support continued stay.
• Assess readmission risk based on established Hospital criteria.
• Demonstrates an understanding of medical necessity and intensity of service, and incorporates payer requirements into the development of a safe, effective, and timely discharge plan.
• Demonstrates an understanding of the patient’s clinical condition, social, and financial resources to determine the most appropriate care setting, practice standards for evaluation, treatment delivery options.
• Incorporates risk of readmission and socio-economic factors in the creation of a safe and individualized transition plan.
• Engages the patient and family/support network in developing the transition plan.
• Collaborates actively with the interdisciplinary team throughout the patient’s stay to re-assess and adjust the plan for care progression and transition according to the patient’s clinical condition.
• Advocates for the patient with the payer and/or IPA to ensure the most effective care progression and transition plan for the patient.
• Coordinates the progression of care to ensure that the ongoing needs of the patient and family are adequately addressed.
• Identifies psychosocial and financial barriers, and collaborates with Clinical Social Work colleagues.
• Identifies discharge planning needs and facilitates transfers to acute and post-acute venues.
• Demonstrates working knowledge of the clinical requirements, individual payer networks and coverage, and impact of patient’s living environment and support network in creating a transition plan.
• Identifies and facilitates home care and durable medical equipment needs at the time of discharge.
• Facilitates palliative or hospice care when needed
• Works collaboratively and maintains active communication with physicians, nursing and other members of the interdisciplinary care team to ensure timely and effective care progression and achievement of desired outcomes.
• Oversees discharge planning and facilitates safe transitions to community settings.
• Addresses/resolves system problems impeding diagnostic or treatment progress.
• Proactively identifies and resolves delays and obstacles to discharge.
• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
• Coordinates and monitors scheduling of tests/procedures of patients and reports results to other healthcare members when appropriate.
• Identifies recurrent problems and recommends strategies for resolution.
• Develops and evaluates case management plans and protocols in collaboration with the interdisciplinary team.
• Evaluates actions taken to assure cost-effective care including physician length of stay, diagnostic related groups cost reporting, morbidity and mortality reports and monitoring of readmissions.
• Utilizes avoidable day reporting tool to identify sources of barriers to patients’ progression of care.
• Serves as a liaison between members of the interdisciplinary care team, community providers, payers, and patient/family to ensure safe and effective plans and smooth transitions between internal and external levels of care.
• Ensures consistent and timely communication with Patient Financial Services and HIM as needed to confirm patient status and/or authorization to support the billing process.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care.
• Collaborates with attending physicians and consultants to review and discuss patient care, progress and identified outcomes. Defines and manages deviations from the plan of care.
• Participates in and or facilitates patient care conferences and family meetings.
• Provides support and clinical expertise for nursing/ancillary personnel related to patient care issues.
• Maintains communication with Nurse Managers and other Case Managers relative to individual patient care and/or system problems.
• Assures prompt reporting of medical/legal issues to Risk Management and appropriate Administrative parties.
• Facilitates peer to peer discussions between attending physicians, Case Management Consultants, and Physician Advisor in cases requiring evaluation and justification of medical necessity for admission by the payer.
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.

Skills

Bilingual Spanish

Basic computer skills

Education

Bachelor of Science in Nursing

Job description

MLK Community Healthcare in Los Angeles, CA seeks a Case Manager to support physicians and the interdisciplinary team, focusing on quality outcomes, patient satisfaction, and cost management. The role coordinates utilization management, care progression and discharge planning to ensure timely and appropriate care.

You will handle caseload management, precertification, payer communications, and collaboration with clinicians.