Hospital Case Manager

Gonzaba Medical Group•San Antonio, TX

1d•Onsite

About The Position

The Hospital Case Manager focuses on concurrent review of Gonzaba Medical Group Managed Care patients in hospital and facility settings. Using nationally recognized care guidelines and patients’ health plan coverage guidelines, the role monitors admissions and continued stays for medical appropriateness and coordinates safe, timely discharge plans with physicians, patients, and families. The HCM advocates for members and their families by connecting them with educational and community resources to support aftercare. Effective utilization management of healthcare resources is a major function of the role. The HCM participates in Patient Care Committee and other medical group or case management team meetings to optimize care, treatment plans, and protocols. The position has no supervisory responsibilities. Work may be entirely in a clinical setting or in an office in a clinical environment, depending on assignment. The role requires driving a company or personal vehicle and maintaining a valid Texas driver license and current vehicle insurance.

Requirements

Minimum high school education or equivalent.
Active, unencumbered Registered Nurse with an associate degree, or state-licensed practical nurse.
Current CPR certification with AED, kept up to date.
Three to five years of RN experience is stated as required.
Four or more years of diverse clinical experience caring for acutely ill adult and geriatric patients with multiple disease conditions.
Computer proficiency, including EMR systems, word processing, spreadsheet, Internet, and database software.
Must successfully complete a motor vehicle history check and maintain a current valid Texas driver license and proof of current insurance if seeking mileage reimbursement.
Must maintain strict member and company confidentiality.
Must provide courteous, tactful customer service in person and through telephone or telehealth applications.
Must be able to work efficiently under pressure.

Nice To Haves

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

Responsibilities

Orient newly enrolled Managed Care patients to Gonzaba Medical Group.
Round daily on assigned Managed Care patients in hospitals and at least weekly on patients in skilled nursing facilities.
Monitor admissions and continued stays for medical appropriateness using nationally recognized care guidelines and health plan coverage guidelines.
Assess medical, physical, psychosocial, and transition needs to anticipate services, equipment, and follow-up care required after discharge.
Develop transitional and discharge plans in consultation with physicians, patients, and families.
Apply knowledge of utilization management, care coordination, and current standards of care to transition planning.
Enter timely and accurate information into the EMR, including pertinent patient and family communications, referral authorizations, and plans.
Collaborate with the case management team regarding coverage determinations, authorizations, and post-discharge follow-up needs.
Communicate regularly with the Managed Care Medical Director about patient status, issues, and questions.
Serve as the clinical liaison with hospital, clinical, and administrative staff.
Provide information about clinical authorizations for inpatient and skilled nursing facility care and milestones toward discharge.
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.
Use individual reasoning to solve problems and make decisions, generally based on prior practice or policy with some interpretation.
Maintain current knowledge of health plan benefits, contracts, and preferred provider networks.
Help guide physicians in understanding preferred contracts, providers, and facilities, with assistance from other Managed Care team members.
Perform Clinical High Risk Home Visits as assigned.
Maintain clinical competencies according to Gonzaba Medical Group policy, uphold customer service expectations, protect confidentiality, participate in educational programs as needed, and perform other assigned duties.