The Care Manager – ER collaborates with the emergency department team to assess potential admissions and determine appropriate status placement using evidence-based criteria such as MCG or third-party review tools. This role supports efficient patient flow by avoiding unnecessary admissions and guiding at-risk patients and families to appropriate community-based resources. The Care Manager – ED facilitates transitions of care, supports discharge planning, and ensures regulatory and documentation requirements are met for patients entering hospice or post-acute services.
Responsibilities
Assesses patients in the emergency department for medical necessity of admission and ensures correct placement into inpatient, observation, or outpatient status using MCG or approved criteria.
Identifies patients who may be appropriate for alternative care settings and works to avoid unnecessary admissions by coordinating with community resources.
Provides timely guidance and education to patients and families regarding care transitions, including hospice services or post-acute facility placement, and secures patient choice documentation as required.
Verifies next of kin contact information and emergency contact, and ensures accurate documentation on patient records.
Collaborates with ED clinicians, hospitalists, care managers, and social services to support seamless transitions of care.
Requirements
Bachelor's Degree in Nursing (BSN) preferred
Nice to have: 1-2 years of experience in care management or utilization review
UM Nurse responsible for medical necessity reviews and care coordination for a population of members, ensuring quality and cost-effective outcomes.
Responsibilities
Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Review cases for medical necessity and apply appropriate clinical criteria including Medicare, Medicaid/Medi-cal, InterQual, Milliman, and Health Plan specific guidelines
Collaborate with the Medical Director to ensure integrity of adverse determination notices
Ensure discharge planning is timely and communicated to transition of care teams
Clinical Registered Nurse role focused on Utilization Management (UM), reviewing clinical documentation to ensure members are in appropriate inpatient settings using InterQual criteria.
Responsibilities
Professional interaction with Acute Inpatient Hospital/Post-Acute Care clinical staff and physicians.
Ensure members are in the most appropriate setting based on severity of illness and intensity of services.
Review clinical documentation provided by the facility.
Apply InterQual criteria.
Interact written, telephonic and verbally with clinical staff internally and externally.
The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, utilizing Indicia for Case Management, and performs clinical reviews through document review, discussion with physicians and collaboration with the care team on the coordination of safe transitions of care.
Responsibilities
Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
Ensures timely identification of need and referral for alternative level of care.
Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
Provides required information to payors in a timely fashion and obtains appropriate authorization for all days.
Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards.
Degrees:
Bachelors.
Licenses & Certifications:
ACMA ACM Certification.
CCMC Case Manager.
AACN Acute/Critical Care Nursing (Adult, Pediatric & Neonatal).
Registered Nurse.
ABMCM Certified Managed Care Nurse.
AAMCN Utilization Review Professionals.
MCG.
ANCC Nursing Case Management.
ACMA Case Management Administrator Certification.
Additional Qualifications:
RNs hired prior to 2/2012 with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN, however,they are required to complete the BSN within 3 years of hire.
RN license & one of the listed certifications is required.
3 years of hospital clinical experience preferred & 2 years of hospital or payor Utilization management review experience required.
Excellent written, interpersonal communication & negotiation skills.
Strong critical thinking skills & the ability to perform clinical chart review abstract information efficiently.
Strong analytical,data management & computer skills/Word /Excel.
Strong organizational & time management skills,as evidenced by capacity to prioritize multiple tasks & role components.
Current working knowledge of payor & managed care reimbursement preferred.
Ability to work independently & exercise sound judgment in interactions with the health care team & patients/families.
Knowledgeable in local, state, & federal legislation & regulations.
Ability to tolerate high volume production st&ards.
MCG Certification or eligible to pursue within 90 days of hire.
Case management,utilization review/surgery pre-anesthesia experience preferred.
Familiar with CPT, ICD-9 &-10 & DRG coding preferred.
Strong ability to research evidence-based practices.
Minimum Required Experience:
4 Years
EOE, including disability/vets
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