Case Manager Certified - Transition in Care

Houston Methodist•The Woodlands, TX

About The Position

Collaborates with the physician and all members of the multidisciplinary healthcare team to facilitate care for designated assignment; monitors the patient’s medical progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective. Independently and effectively communicates with physicians, multidisciplinary care team, patients, families and payers to ensure safe and timely transitions of care. Facilitates clinical conversations with payers to expedite authorization for appropriate post-acute placement based on the clinical condition of the patient. Serves as a preceptor and implements staff education specific to patient populations and department processes, coaches and mentors’ other staff and nursing students. Serves an expert case management resource for department and hospital. Provides education to physicians, nurses, and other healthcare providers on case management topics. Initiates contributions towards improvement of employee engagement as reflected by department scores, i.e., peer-to-peer accountability Proactively identifies discharge barriers and plans and anticipates/prevents and manages emergent situations. Facilitates timely assessment and intervention to prevent or reduce readmission; completion of treatment plan and discharge plan; timely modification of plan of care, based on clinical conditions and changes that may affect the medical treatment and ongoing discharge planning needs of the patient; assignment of appropriate levels of care; completion of all required documentation in designated EMR and applications or programs; elimination of discharge barriers Utilizes advanced knowledge and experience to advise and support care team members to creatively manage complex psychosocial or medical conditions, depending on scope of practice, and proactively formulate discharge plans to decrease avoidable delays. Stays informed and ensures compliance with CMS Conditions of Participation, and other rules and regulations affecting the scope of case management practice. Facilitates referral and transfers for home health care, hospice, durable medical equipment, and post-acute services. Considers social determinants of health into decision-making processes. Conducts comprehensive clinical reviews of the chart for appropriate level of care, medical necessity for continuous hospitalization and for identification of discharge readiness. Documents assessment and interventions within the scope of practice efficiently and effectively. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Conducts post-discharge review by analyzing the inpatient record to ensure that compliance with quality indicators are met. Intervenes and takes appropriate action to foster real-time compliance with CMS guidelines and other performance measures associated with certification programs and other regulatory, national, regional or locally- sponsored quality programs. Provides reports, as needed, to appropriate parties showing compliance with established government and/or institutional rules and regulations; analysis of problematic areas; actions taken to improve compliance; partners with Business Practice. Performs peer-to-peer evaluations for continuous quality improvement. Tracks and trends noncompliance issues and formulates appropriate PDCA. Reports quality of care concerns to appropriate governing body. Identifies opportunities to improve patient satisfaction with focus on discharge and care coordination domains. Collaborates with department leadership to implement evidence-based patient engagement strategies. Proactively manages Length of Stay (LOS) for assigned cases on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Contributes to meeting department and hospital financial targets, with a focus on length of stay management. Educates and supports timely discharges for uninsured and hospitalized outpatients, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital. Partners with CM leadership for LOS and medical appropriateness for resource utilization. Proactively identifies opportunity for practice changes. In collaboration with management, independently implements innovative solutions through evidence-based practice/ performance improvement projects and shared governance 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.

Requirements

Bachelor’s degree or higher from an accredited school of Nursing
Five years hospital clinical nursing experience which includes two years in case management
RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM
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
Comprehensive knowledge of Medicare, Medicaid and Managed Care requirements
Comprehensive knowledge of community resources, health care financial and payor requirements/issues, and eligibility for state, local and federal programs
Comprehensive 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
Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components
Demonstrates critical thinking and makes decisions using evidence-based analytical approach in interactions with physicians, payors, and patients and their families
Competent computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint and Word)

Nice To Haves

Master’s degree preferred

Responsibilities

Collaborates with the physician and all members of the multidisciplinary healthcare team to facilitate care for designated assignment; monitors the patient’s medical progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective.
Independently and effectively communicates with physicians, multidisciplinary care team, patients, families and payers to ensure safe and timely transitions of care. Facilitates clinical conversations with payers to expedite authorization for appropriate post-acute placement based on the clinical condition of the patient.
Serves as a preceptor and implements staff education specific to patient populations and department processes, coaches and mentors’ other staff and nursing students. Serves an expert case management resource for department and hospital. Provides education to physicians, nurses, and other healthcare providers on case management topics.
Initiates contributions towards improvement of employee engagement as reflected by department scores, i.e., peer-to-peer accountability
Proactively identifies discharge barriers and plans and anticipates/prevents and manages emergent situations. Facilitates timely assessment and intervention to prevent or reduce readmission; completion of treatment plan and discharge plan; timely modification of plan of care, based on clinical conditions and changes that may affect the medical treatment and ongoing discharge planning needs of the patient; assignment of appropriate levels of care; completion of all required documentation in designated EMR and applications or programs; elimination of discharge barriers
Utilizes advanced knowledge and experience to advise and support care team members to creatively manage complex psychosocial or medical conditions, depending on scope of practice, and proactively formulate discharge plans to decrease avoidable delays.
Stays informed and ensures compliance with CMS Conditions of Participation, and other rules and regulations affecting the scope of case management practice. Facilitates referral and transfers for home health care, hospice, durable medical equipment, and post-acute services. Considers social determinants of health into decision-making processes.
Conducts comprehensive clinical reviews of the chart for appropriate level of care, medical necessity for continuous hospitalization and for identification of discharge readiness. Documents assessment and interventions within the scope of practice efficiently and effectively. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge.
Conducts post-discharge review by analyzing the inpatient record to ensure that compliance with quality indicators are met. Intervenes and takes appropriate action to foster real-time compliance with CMS guidelines and other performance measures associated with certification programs and other regulatory, national, regional or locally- sponsored quality programs. Provides reports, as needed, to appropriate parties showing compliance with established government and/or institutional rules and regulations; analysis of problematic areas; actions taken to improve compliance; partners with Business Practice.
Performs peer-to-peer evaluations for continuous quality improvement. Tracks and trends noncompliance issues and formulates appropriate PDCA. Reports quality of care concerns to appropriate governing body.
Identifies opportunities to improve patient satisfaction with focus on discharge and care coordination domains. Collaborates with department leadership to implement evidence-based patient engagement strategies.
Proactively manages Length of Stay (LOS) for assigned cases on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Contributes to meeting department and hospital financial targets, with a focus on length of stay management.
Educates and supports timely discharges for uninsured and hospitalized outpatients, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
Partners with CM leadership for LOS and medical appropriateness for resource utilization.
Proactively identifies opportunity for practice changes. In collaboration with management, independently implements innovative solutions through evidence-based practice/ performance improvement projects and shared governance 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.