Description
At Houston Methodist, the Case Manager (CM) position is a registered nurse (RN) responsible for comprehensively planning for case management, which includes care transitions and discharge planning of a targeted patient population on a designated unit(s) and/or service lines. This position works with the physicians and interprofessional health care team to facilitate and maintain compassionate, efficient, quality care and achievement of desired treatment outcomes. The CM position holds joint accountability with the social worker for discharge planning and continuity of care and assures that admission and continued stay are medically necessary, communicating clinical information to payors to ensure reimbursement.
**PEOPLE ESSENTIAL FUNCTIONS**
+ Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner; listens and responds to the ideas of others.
+ Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care. Uses a structured format for regular communication with patients and families.
+ Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Contributes towards improvement of department scores for employee engagement, i. e. peer-to-peer accountability.
**SERVICE ESSENTIAL FUNCTIONS**
+ Assesses all patients timely and thoroughly. Participates in daily Care Coordination Rounds (CCR), and identifies, communicates barriers to efficient patient throughput. Supports patients and families in preventing/resolving clinical or ethical issues.
+ Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interprofessional health care team, as well as patient and family, on complex discharges. Maintains ownership of the discharge planning process on assigned units.
+ Initiates and facilitates referrals for home health care, hospice, and durable medical equipment. Consults with Social Worker Case Manager to assess psychosocial needs associated with transition to alternative levels of care, ensuring discharge disposition is to the appropriate level. Facilitates transfers.
**QUALITY/SAFETY ESSENTIAL FUNCTIONS**
+ Modifies care based on continuous evaluation of the patient's condition, demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. Documents accurate assessment and interventions efficiently and effectively.
+ Plans for routine discharge and elevates emergent situations. Manages usual patient assignment and other unit demands and anticipates/plans for potential problems.
+ Focuses on discharge domain by contributing to department and hospital targets for quality, patient satisfaction and safety measures.
**FINANCE ESSENTIAL FUNCTIONS**
+ Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using nationally recognized screening guidelines. Manages assigned patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
+ Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay.
+ Participates in denial mitigation activities to ensure appropriate reimbursement for services rendered.
+ Contributes to meeting department and hospital financial target, with focus on length of stay. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.
**GROWTH/INNOVATION ESSENTIAL FUNCTIONS**
+ Identifies areas for improvement based on understanding of evidence-based practice literature. Initiates evidence-based practice/performance improvement projects based on these observations and offers solutions by participating in unit projects and activities.
+ Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis.
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
**EDUCATION**
+ Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
+ Bachelor's degree preferred
**WORK EXPERIENCE**
+ Three years hospital nursing clinical experience
+ Case management experience preferred
**LICENSES AND CERTIFICATIONS - REQUIRED**
+ RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days **OR**
+ RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
**KNOWLEDGE, SKILLS, AND ABILITIES**
+ Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
+ Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
+ Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
+ Knowledge of Medicare, Medicaid and Managed Care requirements
+ Progressive knowledge of community resources, health care financial and payor requirements/issues, and eligibility for state, local and federal programs
+ Progressive knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement
+ Understanding of pre-acute and post-acute venues of care and post-acute community resources
+ Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families
+ Well versed in computer skills of the entire Microsoft Office Suite (Excel, Outlook, PowerPoint and Word)
+ Strong assessment, organizational and problem-solving skill
**SUPPLEMENTAL REQUIREMENTS**
**WORK ATTIRE**
+ Uniform No
+ Scrubs No
+ Business professional Yes
+ Other
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