Registered Nurse (RN) - Case Management
Excela Westmoreland Hospital
Greensburg, PA

CASE MANAGER RN - ED

The ED Case manager assesses, coordinates, facilitates, and negotiates services and resources for the ED population in order to achieve desired clinical and financial outcomes. The ED CM reviews clinical criteria to ensure the appropriate level of care for patients presenting to the Emergency Department, as well as those patients referred directly from the physician's office. After review of clinical data and application of objective screening criteria (InterQual Level of Care criteria), the ED CM will consult with the Emergency Department Physician for recommendations regarding appropriate patient status, i.e. acute inpatient admission vs. observation services vs. an alternate level of care, prior to contact with the attending physician. The ED CM coordinates discharge plans for those ED patients requiring follow-up or post-ED care after discharge from the ED, including referrals to Personal Care, Skilled Nursing Facility placement, Home Health, Durable Medical Equipment, etc. Essential Job Functions * PROFESSIONAL ROLE * Maintains professional and technical knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies. * Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following system/hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations. * Protects patients and employees by adhering to infection-control policies and protocols. * Documents patient status recommendations, care coordination, and discharge planning by charting in patient records. * Maintains continuity among the multidisciplinary team by documenting and communicating actions, irregularities, and continuing needs. * Maintains patient confidence and protects operations by keeping information confidential. * Ensures safe and effective transitions of care through standard work that help to promote positive health care outcomes for Excela Health patients. * CLINICAL ROLE * Assesses, plans, implements coordinates, and monitors and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes. * Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Provides crisis management for clients; makes linkages for interventions as appropriate. * Initiates care coordination strategies that are evidence-based and outcome focused. * Identifies patient care requirements by establishing personal rapport with patients, and care givers that need to understand care requirements. * Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families. * Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions. * Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel. * Demonstrates competencies of clinical reasoning and critical-thinking skills for managing complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally competent care. * Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care. * LEADERSHIP ROLE * Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time. * Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing re-admissions and poor health outcomes. * Facilitates the flow of care to expedite appropriate discharge and prevent readmissions. * Assumes the leadership role in achieving outcomes and making the health system work for the patient. * Brings access, understanding and knowledge of the community and the resources to support management of chronic illness. * Resolves patient problems and needs by utilizing multidisciplinary team strategies. * Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods. * Contributes to team effort by accomplishing related results as needed. * Implements effective care coordination strategies that are evidence-based and outcome focused. * Other duties as assigned. Specialty Essential Functions * Level of Care Management * Reviews clinical criteria of all ED / Direct Admission patients for appropriate patient status (i.e. inpatient, observation services, outpatient testing/treatment) based on medical necessity criteria. * Discusses recommendations for level of care with ED physician and attending physician. * Discusses options for care with patients, families, and physicians involved in their care. * Remotely monitors bed board (where applicable). * Psychosocial * Assists patients and their families through the complex emergency room environment and/or the hospitalization process. * Provides emotional support to patients and their families/support system as needed. * Connects patients and their families/support system to community services as needed and appropriate. * Discharge Planning / Case Management * Plans, coordinates, and implements discharge plans for ED and ED hold patients, including but not limited to, referrals to skilled nursing facilities, personal care homes, home health, DME, drug and alcohol treatment facilities, transportation, or community-based services. * Coordinates authorization for admitted patients and/or patients transferred from the ED. * Provides case management follow through for the Unit Based Case Manager on cases requiring follow-through after normal business hours. * Professional Development * Attend meetings as appropriate and meet regularly with supervisor to exchange pertinent information. * Participates in continuing education activities, remaining knowledgeable in area(s) or expertise. * Maintains a high level of ethical conduct regarding confidentiality, dual-relationships and professional stature. * Maintains patient and program records in accordance with applicable standards and regulations, grant requirement, etc. * Utilization * Applies InterQual level of care criteria for Severity of Illness/Intensity of Service Indicators for potential admissions and ED hold patients. Makes referral to Physician Advisor for second level review for patients in the ED hold not meeting inpatient criteria. * Recognizes and progresses the plan of care when an alternative level of care is appropriate. * Collaborates with the attending physician and multidisciplinary healthcare team to facilitate the progression of the plan of care. * Cognizant of payor requirements for all patients in assigned caseload. Responsible for understanding and communicating plan benefit limits/availability to patient or their representative in management of case as necessary. * Responsible for accurate and timely documentation in recognized databases to support Clinical Resource Management and ED components for each patient in assigned caseload. * Denial Management * Initiates contact with the attending physician on cases that do not meet InterQual Level of Care SI/IS indicators in order to clarify plan of care. * Educates physicians and other members of the healthcare team on the application of InterQual Level of Care Criteria to support an acute level of care and provides alternatives to acute care as appropriate. * Notifies the unit-based case manager of all real or potential cases in which an adverse determination or complex psychosocial situation is anticipated. * Identifies and facilitates transition to the most appropriate alternate level of care. Required Qualifications * Graduated of an accredited nursing program. * Two (2) years recent healthcare/clinical experience, or recent clinical experience in an emergency department, case management, or utilization review position. * Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice. * Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience. * Knowledge of payor/insurance benefits * Functional Skills on PC and Related Software (Microsoft Office) * Knowledge of basic office equipment such as copier, fax machine, etc. * Ability to understand and react effectively in a fast-paced environment. Must have flexibility/prioritization skills. Preferred Qualifications * BSN * Case management experience * Case management certification License, Certification & Clearances * Current licensure to practice as a Registered Nurse in the State of Pennsylvania * Act 33 with renewal * Act 34 with renewal * Act 73 FBI Clearance Supervisory Responsibilities * This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department. Position Type/Expected Hours of Work * Incumbent will be scheduled based on operational need (rotating shifts, weekend rotation). * Travel may be expected locally between Excela Health locations. AAP/EEO * Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations. * Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below. Work Environment Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required. Essential - Absolute Necessity. Marginal - Minimal Necessity. Constantly - 5.5 to 8 hours or more or 200 reps/shift. Frequently - 2.5 to 5.5 hours or more or 32-200 reps/shift. Occasionally - 0.25 to 2.5 hours or 2-32 reps/shift. Rarely - Less than 0.25 hours or less than 2 reps/shift. Physical Condition Essential Marginal Constantly Frequently Occasionally Rarely Never Extreme Heat x Extreme Cold x Heights x Confined Spaces X x Extreme Noise(>85dB) x Mechanical Hazards x Use of Vibrating Tools x Operates Vehicle (company) x Operates Heavy Equipment x Use of Lifting/Transfer Devices x Rotates All Shifts x 8 Hours Shifts x x 10-12 Hours Shifts x x On-Call x x Overtime(+8/hrs/shift; 40/hr/wk) x x Travel Between Sites x x Direct Patient Care x x Respirator Protective Equipment x x Eye Protection x x Head Protection (hard hat) x x Hearing Protection X Hand Protection x x Feet, Toe Protection x x Body Protection x x Latex Exposure x x Solvent Exposure X Paint (direct use) Exposure X Dust (sanding) Exposure X Ethylene Oxide Exposure X Cytotoxic (Chemo) Exposure X Blood/Body Fluid Exposure x x Chemicals (direct use) Exposure X Mist Exposure X Wax Stripper (direct use) x x Non-Ionizing Radiation Exposure x Ionizing Radiation Exposure x Laser Exposure x Physical Demands When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required. Essential - Absolute Necessity. Marginal - Minimal Necessity. Constantly - 5.5 to 8 hours or more or 200 reps/shift. Frequently - 2.5 to 5.5 hours or more or 32-200 reps/shift. Occasionally - 0.25 to 2.5 hours or 2-32 reps/shift. Rarely - Less than 0.25 hours or less than 2 reps/shift. Physical Condition Essential Marginal Constantly Frequently Occasionally Rarely Never Bending (Stooping) x x Sitting x x Walking x x Climbing Stairs x x Climbing Ladders x Standing x x Kneeling x Squatting (Crouching) x x Twisting/Turning x x Keyboard/Computer Operation x x Gross Grasp x Fine Finger Manipulation x x Hand/Arm Coordination x x Pushing/Pulling(25lbs.of force) x x Carry x x Transfer/Push/Pull Patients x Seeing Near w/Acuity x x Feeling (Sensation) x x Color Vision x x Hearing Clearly x x Pulling/Pushing Objects Overhead x Reaching Above Shoulder Level x x Reaching Forward x x Lifting Floor to Knuckle ### 10-19 20>50 Lifting Seat Pan to Knuckle ### 10>50 Lifting Knuckle to Shoulder ### 10>50 Lifting Shoulder to Overhead ### 10>50 When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.