ED Utilization Review Case Manager, RN (12 hr shift 7P-7A) Full Time

Job Summary

Establishing a UR process in the Emergency Departments at Pipeline hospitals is an essential component of the revenue cycle. Initial medical necessity reviews are critical as they help determine the appropriate initial placement for patients. During these reviews, the ED UR CM should use our approved tool, InterQual, to help assess the appropriate admission status (inpatient or observation). This reduces future changes to status level of care needed by post-ED discharge (acute, intermediate, critical).

This role will help reduce medical necessity denials, maintain billing compliance with CMS, reduce patient status changes during the hospital stay and prevent self-denials for incorrect status. The ED UR CM role is a 24/7 program that aims to review every patient in the EDs to get the status, inpatient or observation, correct prior to the physician’s order being written. The UR RN will also serve as an educator and resource to the ED staff on why status determination is important and essential. This position will also serve as a resource, in conjunction with Social Work on assisting patients needing discharge to prevent a “social” admission. This position will also serve to complete the initial Discharge Planning Assessment for those “admitted” patients holding in the ED for an inpatient bed. This is a 12-hour position 7 days a week.

Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions

• Provides a warm handoff during shift change to review together all patients in the EDs, identifying potential admissions that need IQ review and physician discussion, patients needing a Discharge Planning Assessment prior to obtaining a bed in house.
• Does initial medical necessity review using IQ on all patients identified as being probable admission and discuss result and guidance for the physician prior to the status admit order being written.
• Discuss IQ review result (inpatient vs observation) with physician, both ED MD and Admitting MD as needed.
• Identify high utilizers in the ED and intervene, consulting SW, to assist patient with post ED discharge needs to minimize avoidable ED and hospital days.
• Completes Initial Discharge Planning Assessment for patients admitted (Obs/Inpt) but holding in the ED waiting for a bed in house.
• Collaborate with ED Admitting department to assure the IMM or MOON are given in the ED prior to admission.
• Collaborate with ED Admitting department to assure authorization obtained for admission and the auth matches the patient’s status, Observation or Inpatient.
• Partner, round and communicate often throughout the shift with the ED RNs, ED MDs, unit clerks and SW in managing patients being admitted or discharged from the ED that may have CM/SW needs.
• Participate in ED huddles/rounds contributing to patient flow strategies.
• Collaborate with patient/family to create a safe and effective transition/discharge plan from the ED as needed.
• Document accurately and completely in the EMR.
• Responds timely to case management consults for patients in the ED.
• Refers patients to SW as a consult as indicated for ED patients.
• Confers with physician for appropriate admission order prior to the order being written.
• Initiates referral to financial counseling for patients needing assistance.
• Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
• Uses AIDET in interactions with patients and family members. Utilizes white boards for patient communication.
• Collaborates across disciplines to assist in coordination of patient care, including but not limited to patient transfer, discharge, referrals, and spiritual/psychosocial support needs.
• Acts with a sense of urgency when performing tasks.
• Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
• Reports on any equipment and or environmental issues for repair.
• Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
• Utilizes SBAR (Situation, Background, Assessment, Recommendation) when communicating with physicians and health care team.
• Speaks up to stop the line and escalates potential safety events if necessary.
• Completes and attends training as assigned.
• Other duties as assigned.
  
  

Behavioral Standards

• Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude.
• Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.
  
  

Communication/Knowledge

• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
  
  

Collaboration/Teamwork

• Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program.
  
  

Qualifications/Experience

• At least two (2) years’ experience as a nurse in an acute care hospital, preferably in an ED setting.
• At least one (1) year’s experience as a UR Nurse/Case Manager in a general acute care hospital.
• Knowledge, experience and proficiency in InterQual essential to this role.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within health care.