The ED Case Manager uses InterQual criteria to evaluate the appropriateness of admissions, level of care, and readiness for discharge. Assures correct level of care: critical, telemetry, acute, observation, for all admissions. Work with physicians to assign/order appropriate designation and medical record documentation. The incumbent leads the development and manages the implementation of the interdisciplinary plan of care for identified patients, involving all members of the health care team as appropriate. Functions as an advisor with accountability to escalate cases to medical leadership as necessary to ensure provision of appropriate and effective patient care.
Minimum 2 years Utilization Management/Case Management experience preferred in an acute care setting.
Working knowledge of Interqual, Intensity of Service/Severity of Illness criteria.
Working knowledge of Title XVII and Title XIX.
Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
Ability to negotiate orders with the physicians in order to assign alternate levels of care.
Working knowledge of community resources.
Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, DME and SNF’s.
Ability to case manage smoothly and increase patient/physician satisfaction while staying within guidelines.
Ability to track outcomes and report findings.
Able to problem solve effectively.
Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required.
Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, positive personal influence and negotiation skills.
Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.
Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.
RN License or LVN License in the State of California required.
Certified Case Manager preferred.