Care Manager I - Transition in Care (Remote - Must Live in Greater Houston)

Notes -

• Selected candidate will work remote after completing onsite department training.
• Selected candidate MUST reside in Greater Houston area.

At Houston Methodist, the Care Manager I position is a licensed registered nurse (RN) who works collaboratively with the interprofessional healthcare team to provide professional nursing care and disease management to various population groups identified in the hospital and ambulatory setting and promotes the achievement of clinical and resource outcomes. This position focuses efforts on patient needs and outreach and coordination of care for a panel of patients promote wellness, decreasing preventable Emergency Department (ED) visits and readmissions while improving patient satisfaction. The Care Manager I position promotes and maintains compassionate, quality transitions of care through collaboration and appropriate communication with all interprofessional health care team members, patients and families. This position participates in department initiatives and shared governance, identifying and assisting with opportunities for performance improvement activities for the programs.

PEOPLE ESSENTIAL FUNCTIONS

• Actively manages assigned panel of patients, using telephonic interaction as the mode of delivery that includes disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient. Facilitates access to care by assessing needs, offering clinical options, and referring to health care providers.

• Elicits, assesses and prioritizes patient information and recommends most appropriate level of care using evidenced-based protocols, working collaboratively and maintaining active communication with physicians, nurses, office staff and other members of the interprofessional healthcare team to resolve problems that are identified during follow-up phone calls.

• Coaches a population and family on self-management support including setting long and short term goals (including acute exacerbation management). Assists in setting SMART goals for self-management, teaching patients how to do self-management tasks and reports abnormal findings to their physician team.

• Serves as a clinical contact for hospital patients post discharge and in the ambulatory setting, working collaboratively and maintaining active communication with physicians, nurses, office staff and other members of the interprofessional healthcare team to resolve problems that are identified during follow-up phone calls.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a patient/employee advocate in preventing/resolving clinical or ethical issues and assists in the identification and improvement to services by proactively identifying and resolving delays and obstacles for the patient.

• Follows patients throughout the care continuum, including inpatient admissions, post hospitalization, and collaborating with inpatient care team management and community resources.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Maintains detailed records to measure effectiveness of program throughout the process.

• Meets patient and patient family needs; takes responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.

• Identifies opportunities to improve patient satisfaction with focus on discharge domain and collaborates with leadership to implement evidence-based patient engagement strategies.

• Participates in collaborative performance improvement activities.

FINANCE ESSENTIAL FUNCTIONS

• Adheres to established productivity benchmarks; participates in decisions impacting operational needs.

• Self-motivated to independently manage time effectively and prioritize daily tasks. Provides input into the unit resource utilization including capital and operational budget needs as appropriate.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Champions new care pathways or service line implementation to improve service to the community. Identifies trends for improvement opportunities or practice changes and supports initiatives. Researches the change and presents options to leadership.

• Identifies and presents areas for innovation, efficiency and improvement in patient care or department operations using evidence-based practice literature. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.

• Identifies own learning needs, consults with healthcare team experts and seeks continuing education opportunities to meet those needs. Seek out committees and events to participate in to develop networks within the HM system.

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 from an accredited school of nursing

WORK EXPERIENCE

• Five years hospital clinical nursing, case management and/or home health experience

• Experience in telehealth triage, emergency medicine, adult ambulatory care preferred