Case Manager (PRN)

At Houston Methodist, the Case Manager PRN (CM) position is a licensed registered nurse (RN) who comprehensively plans case management for a target patient population on a designated unit(s). This position works with physicians and the interprofessional health‑care team to facilitate and maintain compassionate, efficient quality care and achieve desired treatment outcomes. The CM PRN holds joint accountability with social work for discharge planning and continuity of care, ensures that admission and continued stay are medically necessary, and communicates clinical information to payors to secure 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). FLSA STATUS Non‑exempt QUALIFICATIONS Education Graduate of an education program approved by the credentialing body for the required credential(s) indicated below in the Certificates, Licenses and Registrations section. Experience Three (3) years hospital clinical nursing experience, including two (2) years in case management. Licenses and Certifications 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). Skills and Abilities Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations. Proficiency in speaking, reading, and writing English 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 skills 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. Ability to work independently. Demonstrates critical thinking and makes decisions using an evidence‑based analytical approach in interactions with physicians, payors, patients, and families. Well versed in 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 interprofessional health‑care team to facilitate care for a designated case load; monitors patient progress, intervening as needed to ensure that plans 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 plans and discharge plans, modification of plans of care as necessary to meet ongoing patient needs, assignment of appropriate levels of care, and completion of all required documentation in EPIC and MIDAS. Serves as a preceptor, when appropriate, and implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students; serves as 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 or Milliman 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 a 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 collaborates with the team to recommend opportunities for process improvement. Quality/Safety Essential Functions Documents assessment and interventions efficiently and effectively. Plans for routine or difficult discharge and anticipates, prevents, and manages emergent situations; places specific focus on discharge plans and elimination of barriers. Performs post‑discharge review by analyzing the inpatient record to ensure compliance with quality indicators; intervenes and takes appropriate action to foster real‑time compliance with CMS guidelines and other performance measures associated with certification programs and regulatory or 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 a focus on discharge and collaborates with unit leadership to implement evidence‑based patient engagement strategies. Finance Essential Functions Monitors length of stay (LOS) for the case load on an ongoing basis; identifies population and/or service‑specific trends impacting LOS and addresses or resolves problems impeding treatment progress; proactively takes action to achieve continuous improvement and expedite care and facilitate discharge; contributes to meeting departmental financial targets on the 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 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 opportunities for practice change, offers innovative solutions through evidence‑based practice and performance‑improvement projects, and participates in 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 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 (e.g., 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 #J-18808-Ljbffr