Health Solutions Case Manager II

2 months ago

South Houston, United States Memorial Hermann Health System Full time
At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

Responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating options and services required to meet an individual's health needs using communication and available resources to promote quality, cost-effective outcomes.

This role calls for a nurse who is passionate about wellness, enjoys working independently and is a self-starter. Memorial Hermann is partnering with an onsite employer located in the Houston area in support of enhancing the health of their employee population and aiding in improving management of chronic conditions and other health concerns. The Health Navigator role fills a vital need in patient education and advocacy, giving each patient under their care a consistent point of connection to navigate their healthcare journey. Candidates with a clinical nursing background are strongly encouraged to apply; population health or nurse navigator experience are beneficial in this role as well.

This role will require regular onsite visits to the client's locations in the Houston area. Position will meet with employees in one-on-one and group settings to support them in their health journey.

Responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating options and services required to meet an individual's health and wellness needs using communication and available resources to promote quality, cost-effective outcomes.
• Assist with locating in-network providers.
• Assist with coordinating care among providers.
• Provide education regarding levels of care (ED vs. urgent care vs. walk-in clinic).
• Provide assistance with understanding and managing chronic conditions as well as educating about the importance of medication compliance and meeting the standards of care for health conditions.
• Provide assistance with determining health goals and support in achieving and maintaining those goals.
• Partner with the employer to proactively engage specific populations to aid in managing specific conditions.
• Provide health education to groups and individual employees.
• Partner with the employer to promote the Health Navigator program and engagement among employee populations.
• Proactive outreach and relationship building to promote and provide information about the program and build engagement.
• Maintaining program documentation and reporting as indicated.Job Description

Minimum Qualifications

Education: Graduate of an accredited school of nursing (Associates of Nursing or Bachelors of Nursing)

Licenses/Certifications: Current, unrestricted Texas licensure to practice as a Registered Nurse required; CCM certification preferred

Experience / Knowledge / Skills
  • Three (3) to five (5) years clinical experience, three (3) to five (5) years' experience in a Managed Care environment performing case management
  • Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement
  • Strong clinical background in nursing or social services
  • Knowledge of insurance terminology
  • Basic knowledge of computer system
  • Excellent verbal and written communication skills
  • Ability to perform multiple tasks simultaneously, works under pressure, and meet critical deadlines
  • Assertiveness and negotiation skills, which support ability to interact with hospital, discharge planner, physicians and other health care providers
  • Exceptional documentation skills
  • Ability to work independently, manage time and prioritize projects


Principal Accountabilities
  • Demonstrates commitment to Health Solutions behavioral expectations in all interactions and in performing all job duties. Perform job duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety and cost efficiency.
  • Analyzes referrals to accept or deny individuals according to Case Management procedures.
  • Serves as a means for facilitating patient wellness and autonomy though advocacy, communication, education, and identification of service resources.
  • Helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost effective manner in order to obtain optimal value for both the patient and the client.
  • Establish/maintain good rapport with provider to obtain necessary information.
  • Follows Health Solutions guidelines and procedures to make appropriate referrals relative to individual cases (Physician Review, Stop Loss, etc.).
  • Presents all cases when unable to negotiate an acceptable alternative to the Medical Director for determination.
  • Collects accurate data for system input by using correct coding of diagnoses and/or procedures.
  • Enters data into appropriate system and prepare all written communication to patient and/or provider.
  • Adheres to and apply all Health Solutions policies, procedures, and guidelines appropriately.
  • Achieves an in-depth knowledge of client benefit plan.
  • Acts as resource person for Utilization Review staff.
  • Performs other related duties as requested by Supervisor/Director.
  • Processes and maintain confidential information according to confidentiality policy.
  • Negotiates fees with non contracted providers and refer to contracting.
  • Maintains a 90% or greater score on the quarterly audit tool.
  • Communicate, collaborate and cooperate with internal and external stakeholders.
  • Adheres to all Compliance/Program Integrity requirements.
  • Complies with HIPAA Regulations.
  • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann's service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
  • Other duties as assigned.

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