Hospital Case Manager (Concurrent Review Nurse)

Hospital Case Manager

Position Type Full Time Category Managed Care

Description

General Summary: The Hospital Case Manager (HCM) focuses on concurrent review of GMG MC patients (members) in the hospital and facility setting. Utilizing nationally recognized care guidelines and the patient's health plan coverage guidelines, the HCM monitors admissions and continued stays for medical appropriateness. The HCM develops a discharge (DC) plan in coordination with the physician(s), the patient, and the family to promote a safe and timely discharge. They act as an advocate for members and their families by linking them to educational resources and community resources to support their aftercare. Effective utilization management of healthcare resources is a major function of this role. The HCM participates in the Patient Care Committee Meeting (PCC) and other GMG or Case Management (CM) team meetings to optimize care plans, treatment plans and GMG protocols.

Supervisory Responsibilities: This position has no supervisory responsibilities.

General Requirements: All duties performed will be done accurately and in a timely manner.

1. Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
2. Ensures customer service is always maintained at the highest level.
3. Exercises tact and courtesy when dealing with patients, visitors, providers, and co-workers.
4. Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
5. Participates in educational programs as needed.
6. Bilingual English/ Spanish fluency preferred.
7. Other duties as assigned.
8. Maintains strictest member and company confidentiality.

Essential Job Responsibilities:

1. Orients all newly enrolled Managed Care patients to Gonzaba Medical Group.
2. Rounds daily on assigned GMG MC Patients in the hospital setting, and at least weekly on those in the SNF setting.
3. Utilizes nationally recognized care guidelines and the patient's health plan coverage guidelines to monitor admissions and continued stays for medical appropriateness.
4. Assesses the medical, physical, psycho-social and transition needs to anticipate the services, equipment, and follow up care that will be needed upon DC.
5. Confers with physician(s), patient, and families in developing the transitional or DC plan.
6. Demonstrates knowledge of utilization management, care coordination, and current standards of care as a foundation for transition planning activities.
7. Enters timely and accurate information into the EMR to document pertinent patient/family communications, referral authorizations and plans.
8. Collaborates effectively with other members of the GMG CM team to clearly communicate regarding coverage determinations, authorizations, and any special follow up needed post DC.
9. Communicates regularly with the MC Medical Director on patient status, issues, or questions.
10. Serves as the clinical liaison with hospital, clinical and administrative staff. Provides information on the clinical authorizations for inpatient / SNF care and milestones achieved toward DC status.
11. Attends weekly Patient Care Committee (PCC) as census allows.
12. Provides constructive information to patients and families to minimize problems and increase customer satisfaction. Explains and reinforces the physician plan of care.
13. Decision-making is usually based on prior practice or policy, with some interpretation. Must apply individual reasoning to the solution of problems.
14. Maintains current knowledge of health plan benefits, health plan contracts and preferred provider network.
15. With the assistance of other members of the GMG MC teams, guides physicians in their awareness of preferred contracts, providers, and facilities.
16. Performs Clinical High Risk Home Visits as assigned.
17. This position will require driving a company vehicle or a personal vehicle; therefore, employees must successfully complete a motor vehicle history check, possess, and maintain a current valid Texas Driver License, and proof of current insurance to be subject for mileage reimbursement.

Education and Training: Minimum high school education or equivalent. Active, unencumbered Registered Nurse with an associate degree or must be state-licensed practical nurse required. BS in nursing preferred. CPR certification with AED is required and must be kept current. Case Management Certification (CCM) preferred.

Experience: Must have 3-5 years RN experience; 4+ years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions in adult and geriatric populations.

Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Work Environment: Depending upon the area assigned, may be 100% clinical setting, office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.