Case Manager Certified - Full Time - Days

At Houston Methodist the Case Manager (CM)Certified position is a registered nurse (RN) responsible forcomprehensively planning for case management of a targeted patientpopulation on a designated unit(s) and / or service line.

Thisposition works with the physicians and interprofessional healthcareteam to facilitate and maintain compassionate efficient qualitycare and achievement of desired treatment outcomes.

The CMCertified position holds joint accountability with social workersfor discharge planning and continuity of care and assures thatadmission and continued stay are medically necessary communicatingclinical information to payors to ensure reimbursement.

In additionto performing the duties of a CM this position helps drive changeby identifying areas where performance improvement is needed e.

g.daytoday workflow education process improvements patientsatisfaction.

PEOPLE ESSENTIALFUNCTIONS

Collaborates withthe physician and all members of the interprofessional healthcareteam to facilitate care for designated assignment;

monitors thepatients progress intervening as needed to ensure that the plan ofcare and services provided are patientfocused high qualityefficient andcosteffective.

Serves as apreceptor and implements staff education specific to patientpopulations and unit processes; coaches and mentors other staff andstudents.

Serves a resource for department and hospital. Provideseducation to physicians nurses and other healthcare providers oncase managementtopics.

Conducts self in amanner that is congruent with cultural diversity equity andinclusion principles. Initiates contributions towards improvementof department scores for employee engagement i.

e. peertopeeraccountability.

SERVICEESSENTIAL FUNCTIONS

Performsreview for medical necessity of admission continued stay andresource use appropriate level of care and program compliance.

Identifies when services no longer meet InterQual / Milliman lcriteria initiates discussion with attending physicians coordinateswith the external case manager to facilitate discharge planningseeks assistance from the physician advisor if needed and informsmanagement of the possible need for issuing Medicare HospitalInitiated Notice ofNoncoverage.

Appliesapproved utilization criteria to monitor appropriateness ofadmissions level of care resource utilization and continued stay.

Reviews level of care denials to identify trends and collaboratewith team to recommend opportunities for processimprovement.

Plans forroutine / difficult discharge and anticipates / prevents and managesemergent situations. Facilitates timely :

Assessment andintervention to prevent or reduce readmission

completionof treatment plan and discharge plan

modification ofplan of care as necessary to meet the ongoing needs of the patient

assignment of appropriate levels of care

completion of all required documentation in designated EMR andapplications or programs

elimination of dischargebarriers

QUALITY / SAFETYESSENTIALFUNCTIONS

• Documentsassessment and interventions efficiently and effectively.Proactively takes action to achieve continuous improvement andexpedite care / facilitatedischarge.
• Performspostdischarge review by analyzing the inpatient record to ensurethat compliance with quality indicators are met.

Intervenes andtakes appropriate action to foster realtime compliance with CMSguidelines and other performance measures associated withcertification programs and other regulatory national regional orlocally sponsored quality programs.

Provides reports as needed toappropriate parties showing :

compliance with establishedgovernmental and / or institutional rules and regulations

analysis of problematic areas and

actions taken toimprovecompliance

• Conducts chartaudits and performs peertopeer evaluations for continuous qualityimprovement.
• Identifiesopportunities to improve patient satisfaction with focus ondischarge domain and collaborates with unit leadership to implementevidencebased patient engagementstrategies.

FINANCEESSENTIAL FUNCTIONS

MonitorsLength of Stay (LOS) for assigned cases on an ongoing basis.Identifies population and / or servicespecific trends impacting LOSand addresses / resolves problems impeding treatment progress.

Contributes to meeting department and hospital financial targetswith focus on length ofstay.

• Manages all patientsin Observation Status informing physicians of timely dispositionoptions to assure maximum benefits for patients and reimbursementfor the hospital.
• Securesreimbursement for hospital services by communicating medicalinformation required by all external review entities managed carecontracts insurers fiscal intermediaries state and federalagencies.

Responds to requests for information monitors covereddays initiates review to assure that all days are covered andreimbursable.

GROWTH / INNOVATIONESSENTIAL FUNCTIONS

• Identifiesopportunity for practice changes. Offers innovative solutionsthrough evidencebased practice / performance improvement projects andshared governanceactivities.
• Seeksopportunities to identify selfdevelopment needs and takesappropriate action. Ensures own career discussions occur withappropriate management.

Completes and updates the My DevelopmentPlan on an ongoing basis.

This jobdescription is not intended to be allinclusive; the employee willalso perform other reasonably related business / job duties asassigned.

Houston Methodist reserves the right to revise job dutiesand responsibilities as the needarises.

EDUCATION

• Bachelorsdegree or higher innursing
• Masters degreepreferred

WORKEXPERIENCE

Five yearshospital clinical nursing experience which includes two years incase management

LICENSESAND CERTIFICATIONSREQUIRED

• RN Registered NurseTexas State Licensure and / or Compact State Licensure within 60 days OR
• RNTemp Registered NurseTemporary State Licensure within 60 days AND
• Magnet ANCC RecognizedCertification Case Managementrelated OR
• ACM Accredited CaseManager (NBCM) National Board for Case Management

KNOWLEDGE SKILLSAND ABILITIES

• Demonstratesthe skills and competencies necessary to safely perform theassigned job determined through ongoing skills competencyassessments and performanceevaluations
• Sufficientproficiency in speaking reading and writing the English languagenecessary to perform the essential functions of this job especiallywith regard to activities impacting patient or employee safety orsecurity
• Ability toeffectively communicate with patients physicians family members andcoworkers in a manner consistent with a customer service focus andapplication of positive languageprinciples
• Comprehensiveknowledge of Medicare Medicaid and Managed Carerequirements
• Comprehensiveknowledge of community resources health care financial and payorrequirements / issues and eligibility for state local and federalprograms
• Comprehensiveknowledge of discharge planning utilization management casemanagement performance improvement and managed carereimbursement.
• Understandingof preacute and postacute venues of care and postacute communityresources
• Ability to workindependently
• Strongassessment organizational and problemsolving skill as evidenced bycapacity to prioritize multiple tasks and rolecomponents
• Demonstratescritical thinking and makes decisions using evidencebasedanalytical approach in interactions with physicians payors andpatients and theirfamilies
• Competentcomputer skills of the entire Microsoft Office Suite (Access ExcelOutlook PowerPoint andWord)

SUPPLEMENTALREQUIREMENTS

WORKATTIRE

• UniformNo
• Scrubs No
• Businessprofessional Yes
• Other (department approved)No

ONCALL*

• Notethat employees may be required to be oncall during emergencies (ie.DIsaster Severe Weather Events etc) regardless of selectionbelow.
• On Call*Yes

TRAVEL

Travelspecifications may vary bydepartment

• May requiretravel within the Houston Metropolitan areaYes
• May require travel outside HoustonMetropolitan areaNo

CompanyProfile :

Houston Methodist TheWoodlands Hospital opened in June 2017 as the eighth hospital inthe Houston Methodist system. This 267bed 725000squarefootfullservice acutecare hospital offers many of the same services asour flagship hospital in the Texas Medical Center.

• Also on thebeautiful hospital campus located at the intersection of Interstate45 and Texas State Highway 242 are two medical office buildingswhich include a Breast Care Center;
• Cancer Center; infusion center;heart and vascular services; neurology; orthopedics and sportsmedicine; rehabilitation services;

wellness services; an outpatientlaboratory; and several other multispecialty physician practices.In January 2022 Houston Methodist The Woodlands opened HealingTower a $250 million expansion project that added 106 beds focusedon medicalsurgical and womens services and provided nine operatingrooms.

The project also included the expansion of the endoscopycenter emergency department and diagnostic imaging department withan enhanced neurodiagnostic and interventionalcenter.

Houston Methodist is an equal opportunityemployer inclusive of women minorities disabled persons andveterans.

Equal EmploymentOpportunity

Houston Methodist isan Equal Opportunity Employer.

Equal employmentopportunity is a sound and just concept to which Houston Methodistis firmly bound. Houston Methodist will not engage indiscrimination against or harassment of any person employed orseeking employment with Houston Methodist on the basis of racecolor religion sex sexual orientation gender identity nationalorigin age disability status as a protected veteran or othercharacteristics protected by law.

VEVRAA Federal Contractorpriority referral Protected Veteransrequested.