Nurse Case Manager I/II - ED
The Case Manager I/II Emergency Department has an understanding of emergency care, disease processes, utilization management and payer requirements. This position is responsible for taking steps to 1) ensure appropriate ED utilization; 2) place patients in the appropriate status; and 3) meet patient's care coordination needs and mitigate barriers to care. All nursing practice is based on the legal scope of practice, national and specialty standards, Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires registered professional nurses to be responsible and accountable for their own practice. Children's National supports the development of RN relationships within the community; specifically those relationships associated with the health and well being of the community at large. Qualifications
Bachelor's Degree (BSN)
Minimum Work Experience
5 years of related experience. (Required)
ED and pediatric experience preferred. (Preferred)
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.
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.
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.
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.
1. Routinely track Case Management interventions and outcome metrics.
2. Track and trend ED denials. Take steps to reduce denials.
Organizational Accountabilities (Staff)
1. Anticipate and responds to customer needs; follows up until needs are met
1. Demonstrate collaborative and respectful behavior
2. Partner with all team members to achieve goals
3. Receptive to others’ ideas and opinions
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
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