Case Manager Community Access-ED, F/T, 12-8:30pm some holidays and weekends

The MetroHealth System, Cuyahoga County's public health system, and its staff of nearly 8,000 provides care at MetroHealth's four hospitals, four emergency departments and more than 20 health centers and 40 additional sites throughout Cuyahoga County. The health system is home to Cuyahoga County's most experienced Level I Adult Trauma Center, verified since 1992, and Ohio's only adult and pediatric trauma and burn center. As an academic medical center, MetroHealth is committed to teaching and research. Each active staff physician holds a faculty appointment at Case Western Reserve University School of Medicine. Our main campus hospital houses a Cleveland Metropolitan School District high school of science and health. The MetroHealth System is committed to creating a healthier community.

S ummary:

Coordinates the discharge plan for patients requiring case management involvement within the Emergency Department/Clinical Decision Unit, and in accordance with established clinical standards and guidelines. Assesses patients for potential case management intervention. Interacts with third party payers, external case managers, post-acute service providers, and the interdisciplinary team throughout the case management process. Negotiates benefits and care plans between the patient, the interdisciplinary team, the patients' family, and payers. Monitors the effectiveness of the care plan and patient/third party payer satisfaction. Upholds the mission, vision, values, and customer service standards of The MetroHealth System.


1. Serves as a liaison between the interdisciplinary team and payers (including case managers and third party payers) by:

a. Facilitating communication between the interdisciplinary team, patient, patient's family, payer, Patient Accounts, and other departments as required.

b. Coordinating the flow of information regarding benefits, preferred providers, and other key information.

c. Integrating information regarding patient's needs while conversing with the interdisciplinary team and/or the payer source.

d. Attending team conferences, and acting as a coordinator to facilitate the successful achievement of the patient's/team's goals.

e. Coordinating services across healthcare setting for patients not requiring hospital admission, but who are in need of additional healthcare support in the home.

2. Provides clinical expertise by:

a. Utilizing the case management process to facilitate appropriate discharge planning interventions.

b. Identifying treatment plans/goals with the objective of transitioning patients back to their community.

c. Understanding how treatment plans and the goals/objectives for the patient's treatment relate to insurance benefit criteria.

d. Providing objective patient advocacy.

e. Identifying patients at a high risk for hospital readmission, and collaborating with the interdisciplinary team to develop a safe/individualized discharge plan to mitigate that risk.

3. Establishes and maintains links between the patient and care resources (i.e. Case Managers, providers, payers, and community services) by:

a. Working with payers and providers to establish care goals/objectives.

b. Communicating knowledge of the insurance industry, negotiable parameters, and benefits criteria.

c. Communicating treatment plans and goals.

d. Providing necessary documentation to payers as requested.

e. Working with post-acute providers and/or payers to obtain prompt decisions on requested healthcare services to aid in customer/payer satisfaction and throughput within the Emergency Department and/or Clinical Decision Unit.

4. Helps to monitor resource costs (including but not limited to those for benefits and services) by:

a. Providing expertise during any cost/benefit analyses.

b. Accessing appropriate sources to fully investigate benefit/treatment options.

c. Facilitating Utilization Review activities by applying industry standard/appropriate criteria, and assessing medical necessity.

d. Collaborating with the interdisciplinary team to ensure the appropriate level of care for patients who will be admitted to the hospital and/or the Clinical Decision Unit.

a. Identifying discrepancies between treatment plans and documentation that supports the intensity of service/severity of the illness; communicating this information to the physician to add him/her with deciding the most appropriate level of care.

b. Collaborating with the medical team regarding the need to develop alternative plans of care for patients not requiring hospital admission.

c. Monitoring the throughput of patients in observation status in the Clinical Decision Unit.

5. Contributes to the program's effectiveness, maintains follow-up records, and processes evaluations by:

a. Monitoring the outcomes of negotiated treatment plans.

b. Evaluating the quality of services provided, and monitoring patient/payer satisfaction levels.

c. Monitoring increases in volumes of services, and the revenue generated.

d. Assisting with departmental initiatives to maintain high-quality/evidence-based care coordination efforts.

6. Acts as a resource for referral sources and both the Strategic Planning and Managed Care Departments by:

a. Identifies opportunities for program enhancement, on-going program development, and the expansion of services.

b. Marketing unique elements of existing services to external sources.

c. Constructing profiles of payers/referrals for both payer and internal use.

7. Serves as an education resource for patients, their families, caregivers, and the interdisciplinary team by:

a. Assisting patients, their families, and the interdisciplinary team to understand payer/treatment issues.

b. Educating patients/providers/payers regarding alternative care delivery resources, and any other components of the discharge planning process.

c. Educating patients about case management, and identifying opportunities for on-going care education.

d. Assisting new Case Managers with assimilating to their role.

8. Incorporates principles of teamwork in the resolution, completion, and follow-up of responsibilities.

9. Keeps current with trends, developments, and practices in the field as they relate to this work assignment.

10. Performs other functionally related duties as assigned


Bachelors of Science in Nursing (BSN) degree from an accredited institution.
Currently possess a Registered Nurse (RN) license through the State of Ohio Board of Nursing.
3 years of experience in one or more of the following areas: Medical/Surgical, Intensive Care Unit (ICU), or Long-Term Acute Care (LTAC).
Ability to work independently and as a member of an interdisciplinary team.
Effective written, verbal, and interpersonal communication skills.
Effective organizational skills.
Solid clinical reasoning skills.
Ability to prioritize tasks and multitask efficiently.
Basic proficiency with computers and computer software.
Proven history of on-going professional development in a nursing specialty and/or case management within the past 12 months via either current continuing education certificates or a letter from an accredited academic program.

Masters of Science in Nursing (MSN) degree from an accredited institution.
Possess an accepted Case Management Certification from a recognized issuing organization (i.e. a Certified Case Manager (CCM) credential from the Commission for Case Manager Certification (CCMC)).
2 years of experience in one or more of the following areas: Case Management, Discharge Planning, Long Term Acute Care, Home Care, or Care Coordination.
Knowledge of/experience with applying common sets of medical necessity criteria for inpatient care (i.e. InterQual or Milliman).
Experience in a clinical environment.

Physical Requirements:
May sit, stand, stoop, bend, and ambulate intermittently during the day.
May need to sit or stand for extended periods.
See in the normal visual range with or without correction.
Hear in the normal audio range with or without correction.
Finger dexterity to operate office equipment required.
May need to lift up to twenty-five (25) pounds on occasion.
Ability to communicate in face-to-face, phone, email, and other communications.
Ability to see computer monitor and departmental documents.
Requires some exposure to communicable diseases or body fluids.
Requires some exposure to chemicals.