Case Manager

2 weeks ago

The Woodlands, United States Houston Methodist The Woodlands Hospital Full time

At Houston Methodist, the Case Manager PRN (CM) position is a licensed registered nurse (RN) who comprehensively plans for case management of a target patient population on a designated unit(s). This position works with the physicians and interprofessional health care team to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes. The CM PRN holds joint accountability with social worker for discharge planning and continuity of care and assures that admission and continued stay are medically necessary and communicates clinical information to payors to ensure reimbursement. The CM PRN helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements, patient satisfaction).

PEOPLE ESSENTIAL FUNCTIONS
  • Collaborates with the physician and all members of the interprofessional health care team to facilitate care for designated case load; monitors the patient's progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective; facilitates timely:
    - completion and reporting of diagnostic testing;
    - completion of treatment plan and discharge plan;
    - modification of plan of care, as necessary, to meet the ongoing needs of the patient;
    - assignment of appropriate levels of care;
    - completion of all required documentation in EPIC and MIDAS
  • Serves as a preceptor, as appropriate, and implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. Serves a resource for case management and social work resources and needs for the department and the hospital.

SERVICE ESSENTIAL FUNCTIONS
  • Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance. Identifies when services no longer meet InterQual/Millman l criteria, initiates discussion with attending physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from the physician advisor, if needed, and informs management of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage.
  • Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborate with team to recommend opportunities for process improvement.

QUALITY/SAFETY ESSENTIAL FUNCTIONS
  • Documents assessment and interventions efficiently and effectively.
  • Plans for routine/difficult discharge and anticipates/prevents and manages emergent situations. Specific focus given to discharge plan and elimination of barriers.
  • Performs 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 governmental and/or institutional rules and regulations
    - analysis of problematic areas, and
    - actions taken to improve compliance
  • Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.
  • Identifies opportunities to improve patient satisfaction with focus on discharge domain and collaborates with unit leadership to implement evidence-based patient engagement strategies.

FINANCE ESSENTIAL FUNCTIONS
  • Monitors Length of Stay (LOS) for case load on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Contributes to meeting departmental financial target on scorecard
  • Manages all patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
  • Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, and state and federal agencies. Responds to requests for information, monitors covered days, and initiates review to assure that all days are covered and reimbursable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS
  • Provides education to unit-based physicians, nurses, and other healthcare providers on any case management topics.
  • Identifies opportunity for practice changes. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.
  • Identifies and presents areas for innovation, efficiency and improvement in case management or department operations using evidence-based practice literature. Completes and updates the individual development plan (IDP) on an on-going basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. EDUCATION
  • Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certificates, Licenses and Registrations section.

WORK EXPERIENCE
  • Three (3) years hospital clinical nursing experience which includes two (2) years in case management
LICENSES AND CERTIFICATIONS - REQUIRED
  • RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR
  • RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
KNOWLEDGE, SKILLS, AND ABILITIES
  • 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.
  • Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components
  • Knowledge of Medicare, Medicaid and Managed Care requirements
  • Comprehensive knowledge of community resources, health care financial and payer 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.

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