Lead Care Manager - Transition in Care

PEOPLE ESSENTIAL FUNCTIONS

• Participates in the recruitment and interview process for all new hires. Coordinates and provides new staff orientations, including EMR training, documentation training, community resource training and telephonic interviewing training as needed. Provides assessment and feedback of new staff at 30, 60 and 90 days with findings to management. Assesses, recognizes and resolves staff operational needs.

• Serves as the expert Care Management resource for all Care Navigator staff. Assists staff by providing advice, guidance and handling of emergent or urgent calls that need to be escalated to next level of supervision that are within the Lead Care Manager's scope of professional practice. Leads and reports on interventions for transitions of care and population health initiatives, ensuring optimal communication and planning between staff and other teams across different settings. Provides coverage for staff in the absence of the manager.

• Develops teamwork activities, builds awareness of overall department work environment, consistently offers assistance, and responds positively to requests for assistance. Initiates and lead team huddles, meetings as needed. Serves as a backup for management in the department. Collaborates with other staff members and communicate regularly to promote team-based care and shared-decision making. Leads initiates to improve department scores for turnover/retention/engagement.

SERVICE ESSENTIAL FUNCTIONS

• Identifies, develops and executes appropriate disease management activities and interventions such as, but not limited to, individual and/or group contacts and training classes.

• Facilitates identification, adoption, implementation and utilization of ¿best practice¿ clinical practice guidelines and protocols for management of specific diseases/ conditions.

• Proactively identifies and resolves delays and obstacles to services for the patient. Serves as a patient/client/staff advocate and assists in the identification and improvement of service delivery. Leads unit/organizational/system activities to improve patient satisfaction and throughput metrics, through peer-to-peer accountability.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Creates practices for quality and process improvement initiatives, implementing improvement processes for work flow and outcome metrics include (but are not limited to) patient satisfaction, readmissions, cost-per-case, and compliance with care paths or evidence-based guidelines.

• Using resources available, develops, disseminates and monitors protocols and processes to ensure proper documentation, assessments and notifications are completed for populations being served. Implements risk reduction strategies related to health, safety and function.

• Conducts collaborative performance improvement activities for staff, providing interventions and feedback to manager and involved staff. Performs quality monitoring for staff performance which includes but not limited to: day-to-day staff productivity and telephonic monitoring, and addresses deficiencies or underperformance and methods for improvement.

• Leads an evidence-based practice change, performance improvement or research project for service-line/organization/system that meets the requirements of an empirical outcomes (EO) Magnet exemplar to improve quality and safety scores.

FINANCE ESSENTIAL FUNCTIONS

• Keeps staff on task, operating within deadlines and budget. Initiates, leads, and manages multiple projects simultaneously. Collaborates with leadership in assessing and planning for future projects, staffing and budget needs.

• Supports department/organizational strategies to achieve financial targets and mentors others to do the same through timely documentation of care, optimizing efficiency, and other areas according to department specifications.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Develops initiatives and processes to address program needs. Assists in clinical review and assessment of future program opportunities, including participating and leading internal and external interprofessional meetings, as needed. Provides feedback, instruction, and development guidance to help others to excel in their current or future job responsibilities; plans and supports the development of individual skills and abilities.

• Translates strategic priorities into operational reality; aligns communication, accountabilities, resource capabilities, internal processes, and ongoing measurement systems to ensure that strategic priorities yield measurable metrics and sustainable results.

• 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 on-going basis.

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

• Master's degree preferred

WORK EXPERIENCE

• Eight years clinical nursing experience

• Five years care management or related nursing discipline, telehealth preferred

• Chronic disease management experience preferred