ED Clinical Care Coordinator; ED C3) Per Diem- Care Navigation

Welcome to Montage Health’s application process!

Job Description:

Position Summary The ED Clinical Care Coordinator is the gatekeeper of the Emergency Department, providing the Hub early visibility of admissions to enable proactive bed planning, ensuring every admission is appropriately statused, and preventing unnecessary admissions.

• Serves as the ED clinical spoke of the Care Navigation Hub, maintaining awareness of ED demand, boarding volume, anticipated admissions, and barriers to patient progression.
• Works with the Care Navigation Hub to prevent boarders by recommending appropriate bed placement to accommodate current capacity constraints
• Works proactively with ED physicians, charge nurses, and interdisciplinary staff to identify and anticipate potential admissions, observation patients, discharges, and anticipated care needs.
• Tracks patient flow and throughput in the ED, stepping in or escalating to prevent barriers from causing avoidable delays
• Collaborates with the Care Navigation Hub to facilitate timely and appropriate patient placement and disposition.
• Partners with Ancillary services to identify and prevent inappropriate ED testing and facilitate the treatments in the outpatient setting
• Updates and confirms bed requests to ensure accurate patient information and appropriate placement based on clinical needs, patient attributes, and required resources.
• Identifies and escalates barriers to admission, transfer, placement, progression, and discharge.

• Serves as the clinical resource for appropriate patient disposition, collaborating with physicians regarding inpatient admission, observation, outpatient treatment pathways, discharge, and alternative levels of care.
• Discusses and advises physicians regarding patient status determination and patients who may not meet criteria for inpatient admission.
• Serves as a consultant and educator to medical staff regarding patient status, bed placement, payer requirements, and appropriate utilization of hospital resources.
• Initiates the physician peer review process when appropriate.
• Identifies patients who may benefit from alternative treatment or referral pathways and determines the appropriate clinical referral or interdisciplinary resource.
• Collaborates with physicians and interdisciplinary teams to ensure disposition decisions are clinically appropriate and aligned with patient needs.

• Initiates discharge and transition planning at ED presentation when needs are anticipated.
• Identifies clinical, functional, social, equipment, medication, transportation, caregiver, and post-acute needs that may impact safe disposition.
• Develops or facilitates the clinical discharge plan in collaboration with physicians, nursing, C3a, Social Work, and other interdisciplinary partners.
• Identifies patients requiring additional services or resources and directs the ED C3a or appropriate interdisciplinary resource to facilitate referrals and follow-up.
• Addresses or escalates barriers that may prevent a safe or timely discharge.

• Identifies patients at increased risk for readmission, repeat ED utilization, care fragmentation, or poor transition outcomes.
• Coordinates care planning for frequent ED utilizers and medically complex patients in collaboration with the interdisciplinary team and established Care Navigation programs.
• Identifies barriers to ongoing care and determines appropriate clinical and community resources to address those barriers.
• Collaborates with the Care Navigation Hub and ED C3a to ensure identified needs are connected to appropriate resources and services.

• Continues Care Navigation activities for admitted patients boarding in the ED, including identification and escalation of barriers to inpatient placement and progression.
• Identifies patient-specific placement needs such as oxygen, sitter requirements, isolation, equipment, specialty services, or other clinical requirements that may affect bed placement.
• Coordinates with the Care Navigation Hub and inpatient teams to resolve barriers to placement.
• Coordinates interfacility EMTALA transfers in partnership with physicians, transfer centers, receiving facilities, and other stakeholders.
• Escalates delays related to diagnostics, consultations, transportation, environmental services, physician decision-making, bed availability, or other barriers affecting patient flow.