Care Manager -Emergency Room Care Manager 9AM-7PM Monday-ThursdayGalveston, Texas, United StatesNewNursing & Care ManagementUTMB HealthRequisition # 2400472REQUIRED EDUCATION / EXPERIENCE:RN with Bachelor's degree in Nursing and two years of inpatient experience in a hospital environment. Current license or valid permit to practice professional nursing in Texas.JOB DESCRIPTION:To support the physician and interdisciplinary team in the provision of patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management, care coordination and discharge planning functions.ESSENTIAL JOB FUNCTIONS:
Utilization Management
Ensure clear admit status andtimely management of observation patients
Demonstrates knowledge of CMS guidelines and use of Local Coverage Determination (LCD) or inpatient and observation,CMS inpatient only list, and other payor guidelines as required
Demonstrates thorough knowledge in the application of InterQual criteria; Severity of illness (SI), Intensity of service (IS), Discharge screens (DS) SI, IS, and performs continued stay reviews for Medicare, Medicaid and self pay patients
Demonstrates skill in accurately entering required UM data. Works closely with denials/appeals coordinator
Elevate to department leadership all patients not meeting medical necessity criteria after impasse with attending physician
Creates final patient discharge disposition (closing of cases)
Level of Care:
Ensure appropriate level of care/patient status
Facilitate clinical care progression of patient by multidisciplinary team throughout stay
Demonstrates knowledge of CMS guidelines and use of LCD for inpatient and observation,CMS inpatient only list, and other payor guidelines as required
Demonstrates appropriate application of InterQual LOC criteria to evaluate current patient care needs.
Elevate to department leadership all patients in an inappropriate level of care after impasse with attending physician
Documents avoidable days
Assessment of patients’financial, emotional, physical, social, functional and health care needs
Demonstrates ability to assess discharge needs of all patients, and ability to prioritize patients by need, e.g. Medicare, high risk diagnoses, high risk for readmission, identified vulnerable patients
Identify readmission risk and target interventions to reduce risk for readmission
Define and recommend potential discharge plan
Utilize assessment to begin management of patient and family expectations regarding the plan of care
Care Coordination of Treatment Plan: Medical and Multidisciplinary
Participate in multidisciplinary rounds. Facilitates clinical care progression of multidisciplinary team in a timely and efficient manner
Facilitate Patient Care conferences based on patient/family needs
Manage patient and family expectations the plan of care
Contact appropriate ancillary department with any delays impacting care progression
Address incomplete, unclear medical plan of care with attending physician. If unsuccessful, elevate to department leadership, director or physician advisor as appropriate.
Salary:Salary commensurate with experienceEqual Employment OpportunityUTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.Compensation
