Case Manager Certified - Full Time - Days
Company: Houston Methodist The Woodlands Hospital
Location: Conroe
Posted on: May 3, 2024
Job Description:
At Houston Methodist, the Case Manager (CM) Certified position
is a registered nurse (RN) responsible for comprehensively planning
for case management of a targeted patient population on a
designated unit(s) and/or service line. This position works with
the physicians and interprofessional healthcare team to facilitate
and maintain compassionate, efficient quality care and achievement
of desired treatment outcomes. The CM Certified position holds
joint accountability with social workers for discharge planning and
continuity of care and assures that admission and continued stay
are medically necessary, communicating clinical information to
payors to ensure reimbursement. In addition to performing the
duties of a CM, this position 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 healthcare team to facilitate care for designated
assignment; 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.
- Serves as a preceptor and implements staff education specific
to patient populations and unit processes; coaches and mentors
other staff and students. Serves a resource for department and
hospital. Provides education to physicians, nurses, and other
healthcare providers on case management topics.
- Conducts self in a manner that is congruent with cultural
diversity, equity and inclusion principles. Initiates contributions
towards improvement of department scores for employee engagement,
i.e., peer-to-peer accountability.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/Milliman 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.
- Plans for routine/difficult discharge and anticipates/prevents
and manages emergent situations. Facilitates timely:
- Assessment and intervention to prevent or reduce readmission
- 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 designated EMR and
applications or programs
- elimination of discharge barriersQUALITY/SAFETY ESSENTIAL
FUNCTIONS
- Documents assessment and interventions efficiently and
effectively. Proactively takes action to achieve continuous
improvement and expedite care/facilitate discharge.
- 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 assigned cases on an ongoing
basis. Identifies population and/or service-specific trends
impacting LOS and addresses/resolves problems impeding treatment
progress. Contributes to meeting department and hospital financial
targets, with focus on length of stay.
- Manages all patients in Observation Status, 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, state, and
federal agencies. Responds to requests for information, monitors
covered days, initiates review to assure that all days are covered
and reimbursable.GROWTH/INNOVATION ESSENTIAL FUNCTIONS
- Identifies opportunity for practice changes. Offers innovative
solutions through evidence-based practice/performance improvement
projects and shared governance activities.
- Seeks opportunities to identify self-development needs and
takes appropriate action. Ensures own career discussions occur with
appropriate management. Completes and updates the My Development
Plan 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
- Bachelor's degree or higher in nursing
- Master's degree preferredWORK EXPERIENCE
- Five years hospital clinical nursing experience which includes
two 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 AND
- Magnet - ANCC Recognized Certification Case Management-related
OR
- ACM - Accredited Case Manager (NBCM) National Board for Case
Management 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
- Comprehensive knowledge of Medicare, Medicaid and Managed Care
requirements
- Comprehensive knowledge of community resources, health care
financial and payor 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
- Ability to work independently
- Strong assessment, organizational and problem-solving skill as
evidenced by capacity to prioritize multiple tasks and role
components
- Demonstrates critical thinking and makes decisions using
evidence-based analytical approach in interactions with physicians,
payors, and patients and their families
- Competent computer skills of the entire Microsoft Office Suite
(Access, Excel, Outlook, PowerPoint and Word) SUPPLEMENTAL
REQUIREMENTS
WORK ATTIRE
- Uniform No
- Scrubs No
- Business professional Yes
- Other (department approved) No ON-CALL
Note that employees may be required to be on-call during
emergencies (ie. DIsaster, Severe Weather Events, etc) regardless
of selection below.
- On Call Yes TRAVEL
Travel specifications may vary by department
- May require travel within the Houston Metropolitan area
Yes
- May require travel outside Houston Metropolitan area No Company
Profile:
Houston Methodist The Woodlands Hospital opened in June 2017 as the
eighth hospital in the Houston Methodist system. This 267-bed,
725,000-square-foot, full-service, acute-care hospital offers many
of the same services as our flagship hospital in the Texas Medical
Center. Also, on the beautiful hospital campus, located at the
intersection of Interstate 45 and Texas State Highway 242, are two
medical office buildings, which include a Breast Care Center;
Cancer Center; infusion center; heart and vascular services;
neurology; orthopedics and sports medicine; rehabilitation
services; wellness services; an outpatient laboratory; and several
other multispecialty physician practices. In January 2022, Houston
Methodist The Woodlands opened Healing Tower - a $250 million
expansion project that added 106 beds, focused on medical-surgical
and women's services, and provided nine operating rooms. The
project also included the expansion of the endoscopy center . click
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Keywords: Houston Methodist The Woodlands Hospital, College Station , Case Manager Certified - Full Time - Days, Accounting, Auditing , Conroe, Texas
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