Hospital Case Manager

Gonzaba Medical Group•San Antonio, TX

5d•Onsite

About The Position

The Hospital Case Manager (HCM) conducts concurrent review of Gonzaba Medical Group Managed Care (GMG MC) patients in hospital and facility settings. Using nationally recognized care guidelines and the patient’s health plan coverage guidelines, the HCM monitors admissions and continued stays for medical appropriateness and supports effective utilization management of healthcare resources. The HCM assesses medical, physical, psychosocial, and transition needs, then coordinates a safe and timely discharge plan with physicians, patients, and families. The role also connects members and families with educational and community resources to support aftercare. The HCM collaborates with the GMG Case Management team, communicates with the MC Medical Director, serves as a clinical liaison with hospital and facility staff, and participates in Patient Care Committee and other team meetings. The position has no supervisory responsibilities. It requires driving a company or personal vehicle for assigned duties and clinical high-risk home visits. Work may take place in a clinical setting or an office in a clinical environment.

Requirements

At least a high school education or equivalent.
Active, unencumbered Registered Nurse with an associate degree, or state-licensed practical nurse.
Current CPR certification with AED; certification must be maintained.
Three to five years of RN experience and four or more years of diverse clinical experience caring for acutely ill adult and geriatric patients with multiple disease conditions.
Skilled in using computers and EMR systems.
Knowledge of word processing, spreadsheet, internet, and database software.
Ability to work efficiently under pressure and use individual reasoning to solve problems.
For driving duties, successfully complete a motor vehicle history check and maintain a current valid Texas driver license and proof of current insurance for mileage reimbursement eligibility.
Maintain strict member and company confidentiality.

Nice To Haves

Bilingual English/Spanish fluency.
Bachelor of Science in Nursing.
Case Management Certification (CCM).

Responsibilities

Orient newly enrolled Managed Care patients to Gonzaba Medical Group.
Round daily on assigned GMG MC patients in hospitals and at least weekly on patients in skilled nursing facilities.
Use nationally recognized care guidelines and health plan coverage guidelines to review admissions and continued stays for medical appropriateness.
Assess medical, physical, psychosocial, and transition needs to anticipate services, equipment, and follow-up care needed after discharge.
Coordinate transitional and discharge plans with physicians, patients, and families.
Apply knowledge of utilization management, care coordination, and current standards of care to transition planning.
Document patient and family communications, referral authorizations, and plans accurately and promptly in the EMR.
Collaborate with the GMG Case Management team regarding coverage determinations, authorizations, and post-discharge follow-up needs.
Communicate regularly with the MC Medical Director about patient status, issues, and questions.
Serve as the clinical liaison with hospital, clinical, and administrative staff, providing information on inpatient and skilled nursing facility authorizations and discharge milestones.
Attend weekly Patient Care Committee meetings as census allows.
Provide constructive information to patients and families to minimize problems and improve customer satisfaction.
Explain and reinforce the physician’s plan of care.
Maintain knowledge of health plan benefits, contracts, and preferred provider networks, and help guide physicians on preferred contracts, providers, and facilities.
Perform Clinical High Risk Home Visits as assigned.
Maintain clinical competencies, participate in educational programs as needed, and perform other duties as assigned.
Maintain confidentiality and provide courteous, high-quality customer service in person and through telephone or telehealth communication.