Sr Case Manager/Department Educator

Memorial Hermann Health System

About The Position

The Senior Case Manager works with a defined patient population to promote optimal clinical and resource outcomes, facilitate appropriate lengths of stay and reimbursement, and support quality, efficient, patient-centered care. The role manages a complex, resource-intensive patient caseload and coordinates care progression and discharge planning across the continuum. It serves as an information and education resource for the interdisciplinary team, supports organization-wide problem solving, analyzes systems and variances for improvement opportunities, and works with leadership to align goals and visions. The position oversees high-risk, high-cost patient populations; collaborates with physicians and multidisciplinary teams on clinical pathways, care management programs, and performance measurement; and provides education, in-services, mentoring, and precepting. It completes utilization management and quality screening, monitors length of stay and resource use, supports reimbursement and discharge planning, and uses clinical, financial, and patient satisfaction data to drive improvement. The role also ensures clear communication and documentation among patients, families, healthcare teams, and payors, and carries out delegated activities and other assigned duties.

Requirements

Bachelor of Science in Nursing (BSN) or Master of Social Work (MSW) required.
Current, valid Texas Registered Nurse license or current, valid Texas Master Social Worker (LMSW) license required.
Case Manager certification required.
Three years of experience in utilization management, case management, discharge planning, or another cost/quality management program.
At least three years of hospital-based nursing or social work experience.
Excellent interpersonal communication and negotiation skills.
Demonstrated leadership skills.
Strong analytical, data management, and personal computer skills.
Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Understanding of pre-acute and post-acute care settings and post-acute community resources.
Strong organizational and time management skills, including the ability to prioritize multiple tasks and role components.
Ability to work independently and exercise sound judgment when interacting with physicians, payors, patients, and families.
Effective oral and written communication skills.

Nice To Haves

Master’s degree preferred.
Licensed Clinical Social Worker (LCSW) preferred.

Responsibilities

Oversee management of designated high-risk, high-cost patient populations across the continuum and serve as a resource to multidisciplinary teams managing complex patients.
Collaborate with physician leadership and multidisciplinary teams to develop clinical pathways, care management programs, and measures and feedback for cost, quality, service, and patient satisfaction.
Serve as an information resource for case management staff, payors, physicians, healthcare team members, and customers on regulatory requirements, pathway implementation, ethics and healthcare law, and clinical matters.
Facilitate learning experiences and in-services for healthcare team members, serve as a pathway resource, participate in teaching CM Modules, and act as a preceptor or mentor to new hires.
Coordinate and facilitate patient care progression throughout the continuum, maintaining active communication with physicians, nursing, and other care team members.
Identify and resolve issues impeding diagnostic or treatment progress and discharge; seek consultations, use conflict resolution skills, and facilitate timely care.
Monitor patients’ progress and collaborate with the multidisciplinary team to ensure patient-focused, high-quality, efficient, cost-effective care and timely completion of testing, treatment and discharge plans, payor communications, level-of-care assignments, and required documentation.
Work with medical, nursing, and ancillary staff to eliminate barriers to efficient care in the appropriate setting.
Complete utilization management and quality screening for assigned patients; apply approved clinical appropriateness criteria and document findings according to department standards.
Identify at-risk populations using approved screening tools and follow reporting procedures.
Monitor length of stay and ancillary resource use, taking action to improve both; refer cases and issues to the Care Management Medical Director as required and follow up.
Coordinate with the Resource Center on covered-day reimbursement certification, discuss payor criteria and issues with clinical staff, and follow up to resolve payor problems.
Use quality screens to identify potential issues and forward information to the Clinical Quality Review Department.
Ensure plan-of-care information is communicated to patients, families, and healthcare team members and documented to support continuity of care.
Manage discharge planning for assigned patients, including assessing patient and family needs, developing individualized continuing-care plans with physicians, and maintaining consensus among the patient or family, physician, and payor.
Collaborate with the multidisciplinary team throughout discharge planning, including assessment, planning, implementation, teaching, and ongoing evaluation.
Refer appropriate cases for social work intervention; communicate with external case managers; initiate referrals for home health care, hospice, medical equipment, and supplies; and facilitate transfers to other facilities as appropriate.
Participate in clinical performance improvement activities and assist with collection and reporting of financial indicators, including case mix, length of stay, cost per case, excess days, resource use, readmissions, denials, and appeals.
Use fiscal, clinical, and patient satisfaction data to guide decisions and develop and implement performance improvement strategies for assigned patients.
Collect, analyze, and address variances from care plans and pathways with physicians and other team members; collect delay and other performance or outcome data; and document relevant pathway variances and outcomes.
Initiate and lead development, implementation, evaluation, and revision of clinical pathways and other case management tools as part of the clinical resource team.
Assist with physician profile data on length of stay, resource use, denied days, costs, case mix index, patient satisfaction, and quality indicators.
Assist in developing orientation schedules and identifying individual learning needs.
Ensure safe care for patients, staff, and visitors and comply with Memorial Hermann policies, procedures, standards, budget specifications, time management, supply management, productivity, and service quality expectations.
Promote professional growth by meeting mandatory and continuing education and competency requirements, supporting department goals, and serving as a resource to less experienced staff.
Model Memorial Hermann’s service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.
Perform other duties as assigned.
Assume delegated activities from the Director as needed.