Case Manager Certified

FLSA Status: Exempt. This role serves as a preceptor for other case managers and social workers and helps drive performance improvement across workflow, education, and patient satisfaction.

About the role

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. 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.

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, including three years in case management

Licenses and Certifications

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

Knowledge and Abilities

• Demonstrates skills and competencies necessary to safely perform assigned duties, validated through ongoing assessments and performance evaluations
• Sufficient proficiency in speaking, reading, and writing English to perform essential functions, especially regarding patient or employee safety
• Ability to communicate effectively with patients, physicians, families, and co-workers with a customer-service focus and positive language principles
• Comprehensive knowledge of Medicare, Medicaid, and Managed Care requirements
• Comprehensive knowledge of community resources, healthcare 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 skills with capacity to prioritize multiple tasks and role components
• Demonstrates critical thinking and evidence-based analytical decision-making with physicians, payors, patients, and families
• Competent computer skills across the Microsoft Office Suite (Access, Excel, Outlook, PowerPoint, Word)

Essential Functions

People

• Collaborates with physicians and multidisciplinary healthcare team to facilitate care; monitors patient medical progress and intervenes to ensure patient-focused, high-quality, efficient, cost-effective care
• Independently and effectively communicates with physicians, care team, patients, families, and payers to ensure safe, 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 clinical condition
• Serves as preceptor and implements staff education specific to patient populations and department processes; coaches and mentors staff and nursing students
• Serves as expert case management resource for department and hospital
• Provides education to physicians, nurses, and other healthcare providers on case management topics
• Initiates contributions toward improvement of employee engagement (e.g., peer-to-peer accountability)

Service

• Proactively identifies discharge barriers; plans, anticipates, prevents, and manages emergent situations
• Facilitates timely assessment and intervention to prevent or reduce readmission; completes treatment and discharge plans; modifies plan of care based on clinical changes; assigns appropriate levels of care; completes all required documentation in designated EMR and applications; eliminates discharge barriers
• Utilizes advanced knowledge to advise and support care team members in creatively managing complex psychosocial or medical conditions; proactively formulates discharge plans to decrease avoidable delays; escalates discharge barriers to leadership and/or physician advisor
• Stays informed and ensures compliance with CMS Conditions of Participation and other regulations affecting case management scope
• Facilitates referrals and transfers for home health, hospice, durable medical equipment, and post-acute services
• Considers social determinants of health in decision-making

Quality/Safety

• Conducts comprehensive clinical chart reviews for appropriate level of care, medical necessity for continuous hospitalization, and discharge readiness
• Documents assessments and interventions within scope of practice timely, efficiently, and effectively
• Proactively takes action to achieve continuous improvement and expedite care/discharge
• Conducts post-discharge review by analyzing inpatient records to ensure compliance with quality indicators
• Intervenes proactively to foster real-time compliance with CMS guidelines and other performance measures tied to certification programs and regulatory, national, regional, or local quality programs
• Reports to appropriate parties showing compliance with government/institutional rules; analyzes problematic areas; documents 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 cycles
• 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

• Proactively manages Length of Stay (LOS) for assigned cases on an ongoing basis
• Identifies population- and service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress
• Contributes to meeting department and hospital financial targets with focus on LOS management
• Educates and supports timely discharges for uninsured and hospitalized outpatients; informs physicians of timely disposition options to maximize patient benefits and hospital reimbursement
• Partners with CM leadership for LOS and medical appropriateness for resource utilization

Growth/Innovation

• Proactively identifies opportunities 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

• Business professional required
• Uniform: No
• Scrubs: No

On-Call

Yes — employees may be required to be on-call during emergencies (e.g., disaster, severe weather events).

Travel

• May require travel within the Houston Metropolitan area
• No travel outside Houston Metropolitan area required