The Emergency Department Case Manager / Utilization Review Nurse collaborates with all members of the Emergency Department/Clinical Resource Management (CRM) team to review and coordinate the admission of Emergency Department patients; and is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite services for Utilization Review or Case Management. Initiates appropriate clinical pathways based upon diagnosis and serves as a resource person for utilization management purposes as well as partnering with the Social Worker Team to promote smooth transitions for discharge planning.Education
- Bachelor's degree along with current District of Columbia RN license Required
- 1-2 years working in case management and/or emergency department case management Required
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia Required
- CPR - Cardiac Pulmonary Resuscitation Required
- BLS - Basic Life Support Required
- CCM - Certified Case Manager Preferred
Knowledge, Skills, and Abilities
- Knowledge of Medicare, Medicaid, and Third Party payor programs.
- Collaborates with the Emergency Department providers, clinical nurses, and other clinical ancillary staff to assist with the initial patient assessment/review and high-risk screen for the purpose of Utilization Review (UR) Management.
- Initiates a UR screening tool to ensure screening is based on present criteria and communicates to other members of the CRM team or Resource Center according to procedure.
- Assists with referrals to Outpatient, Home Health and/or other agencies as indicated by a Provider order and engages the assistance of the Social Work Team as needed for patient through put.
- Communicates with third party payers to assist with pre-certification, PCP referrals, and waivers.
- Completes in a timely manner, UM admission/observation stay criteria review to obtain
- Identifies high-risk re-admission patients, and communicates, as needed, for UM purposes.
- Refers individual patient reviews that do not meet status criteria to MWHC Physician Advisor as needed.
- Readily distinguishes between acute, intermediate and skilled levels of care.
- Refers concurrent utilization problems/issues to the PA for review.
- Advises the provider of the appropriate commercial insurer requirements, such as Medicare, Medicaid, and/or second opinion requirement.
- Maintains current clinical records according to department policy, professional standards, and prepares monthly statistical reports as designated by Leadership.
- Performs data collection such as tracking (for data analysis) number of CM consults from Healthcare Team, patients referred/transferred directly to another facility set up by CRM, patients referred to Home Health Services & Readmission data; and tracking (for performance improvement) number of level of care changes (OBS vs. INPT) identified by UR RN, potential admissions diverted safely home, pay for performance activities, and clinic referrals.
- Facilitates the
- Basic Life Support
- Case Management
- Certified Case Manager
- Certified Nurse Practitioner
- Clinical Works