Certified Case Manager

At Houston Methodist, the Case Manager (CM) Certified position is responsible for comprehensively planning for case management which includes care transitions and discharge planning of a targeted patient population on a designated unit(s) and/or service line. 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. The CM Certified position is accountable for discharge planning and continuity of care. This position works with patients, families, physicians, and interprofessional healthcare teams to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes. The CM Certified position will serve as preceptor for other case managers and social workers.

FLSA STATUS
Exempt

QUALIFICATIONS

EDUCATION

• Bachelor’s degree or higher from an accredited school of Nursing
• Master’s degree preferred

EXPERIENCE

• Five years of hospital clinical nursing experience, which includes three years in case management

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM or CMC-NACCM or COHN or COHN/CM or CPHRM

KNOWLEDGE AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing 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)

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates with the physician and all members of the multidisciplinary healthcare team to facilitate care for designated assignment; monitors the patient’s medical progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high-quality, efficient, and cost-effective.
• Independently and effectively communicates with physicians, multidisciplinary care team, patients, families and payers to ensure safe and timely transitions of care. Proactively seeks assistance from physician advisor, as needed. Facilitates clinical conversations with payers to expedite authorization for appropriate post-acute placement based on the clinical condition of the patient.
• Serves as a preceptor and implements staff education specific to patient populations and department processes, coaches and mentors’ other staff and nursing students. Serves an expert case management resource for department and hospital. Provides education to physicians, nurses, and other healthcare providers on case management topics.
• Initiates contributions towards improvement of employee engagement as reflected by department scores, i.e., peer-to-peer accountability. Serves as a preceptor for other case managers and social workers.

SERVICE ESSENTIAL FUNCTIONS

• Proactively identifies discharge barriers and plans and anticipates/prevents and manages emergent situations. Facilitates timely assessment and intervention to prevent or reduce readmission; completion of treatment plan and discharge plan; timely modification of plan of care, based on clinical conditions and changes that may affect the medical treatment and ongoing discharge planning 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 barriers
• Utilizes advanced knowledge and experience to advise and support care team members to creatively manage complex psychosocial or medical conditions, depending on scope of practice, proactively formulates discharge plans to decrease avoidable delays, and proactively escalates appropriate discharge barriers to leadership and/or physician advisor.
• Stays informed and ensures compliance with CMS Conditions of Participation, and other rules and regulations affecting the scope of case management practice. Facilitates referral and transfers for home health care, hospice, durable medical equipment, and post-acute services. Considers social determinants of health into decision-making processes.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Conducts comprehensive clinical reviews of the chart for appropriate level of care, medical necessity for continuous hospitalization and for identification of discharge readiness. Documents assessment and interventions within the scope of practice timely, efficiently and effectively. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge.
• Conducts post-discharge review by analyzing the inpatient record to ensure that compliance with quality indicators are met. Intervenes and proactively 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. Reports, as needed, to appropriate parties, showing compliance with established government and/or institutional rules and regulations; analysis of problematic areas; actions taken to improve compliance; partners with Business Practice.
• Performs peer-to-peer evaluations for continuous quality improvement. Tracks and trends noncompliance issues and formulates appropriate PDCA. Reports quality of care concerns to appropriate governing body.
• Identifies opportunities to improve patient satisfaction with focus on discharge and care coordination domains. Collaborates with department leadership to implement evidence-based patient engagement strategies.

FINANCE ESSENTIAL FUNCTIONS

• Proactively manages 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 a focus on length of stay management.
• Educates and supports timely discharges for uninsured and hospitalized outpatients, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
• Partners with CM leadership for LOS and medical appropriateness for resource utilization.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Proactively identifies opportunity for practice changes. In collaboration with management, independently implements 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 ongoing basis.

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

QUALIFICATIONS

EDUCATION

• Bachelor’s degree or higher from an accredited school of Nursing
• Master’s degree preferred

EXPERIENCE

• Five years of hospital clinical nursing experience, which includes three years in case management

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM or CMC-NACCM or COHN or COHN/CM or CPHRM