Care Manager - Transition in Care (Remote)
- Job Ref:
- 53624
- Talent Area:
- Case Management/Social Work
- Job Shift:
- 1st - Day
- Job Type:
- Full-Time
- Posted Date:
- March 1, 2024
At Houston Methodist, the Care Manager position is a licensed, experienced staff nurse responsible for partnering collaboratively with interprofessional healthcare team to provide professional nursing care and disease management to high risk patients and employees identified in the hospital and ambulatory setting. This position focuses efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness, decreasing preventable Emergency Department (ED) visits and readmissions while improving patient satisfaction. The Care Manager communicates with the physicians and the interprofessional health care team to facilitate and maintains compassionate, efficient quality care and achievement of desired treatment outcomes. This position demonstrates compassion and clinical competence when providing care, use of technology, and managing emergencies, and acting as a patient and family advocate in order to monitor and maintain patient rights. This position performs the duties and responsibilities of a Care Navigator as well as mentors new staff and helps drive change by identifying areas where performance improvement is needed and possibly contributing to program or hospital-wide initiatives at management's discretion (e.g., day-to-day workflow, education, process improvements, patient satisfaction).
Requirements:
- Serves as a clinical expert 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 care team to resolve problems that are identified during follow-up phone calls.
- Mentors others in population health and other areas for skills development, coaching improvement, motivational interviewing techniques and other skills as needed. Assists with orientation for all new staff on specific programs.
- Fosters teamwork by awareness of overall department activity, consistently offering assistance, and responding positively to requests for assistance. Collaborates balance within the work unit to foster a healthy work environment. Participates in huddles, meetings and team buildings.
- Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Anticipates needs of other team members; proactively offers assistance. Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.
SERVICE ESSENTIAL FUNCTIONS
- Advocates on patient/family's behalf to identify and resolve clinical and ethical concerns, utilizing appropriate resources and assists in the identification and improvement to services by proactively identifying and resolving delays and obstacles for the patient.
- Cross trains in other population health areas to be able to assist with departmental and staffing requirements as needed.
- Identifies opportunities to improve patient satisfaction through collaboration with the interprofessional healthcare team, with focus on post discharge domain and collaborates with leadership to implement evidence-based patient engagement strategies. Contributes to improving score for patient satisfaction on program-based dashboard, through positive communication, proactive interventions, etc.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
- Assesses and monitors quality of community resources for the department to refer to and report back on patient satisfaction and engagement of the community partners to management. Contributes to meeting department goals and metrics.
- Documents assessment and interventions efficiently and effectively.
- Participates and contributes in department initiatives for quality and process/performance improvement. Presents and reports for the overall specific program, at CM staff meetings and department staff meetings on progress and new initiatives for their program.
FINANCE ESSENTIAL FUNCTIONS
- Adheres to established productivity benchmarks; actively participates in decisions impacting operational and capital needs. Makes suggestions for cost saving measure for their program.
- Contributes towards meeting department financial target on program-based dashboard through displaying self-motivation to independently manage time effectively, timely documentation of care, minimizing incidental overtime, decreasing length of stay, optimizing efficiency and other areas according to departmental specifications.
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 shared governance and leadership. Champion for patient devices and innovation projects.
- Identifies department and cultural changes and presents areas for innovation, efficiency and improvement in patient care or unit operations using evidence-based practice literature. Offers innovative solutions through evidence-based practice/performance improvement projects and 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 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.
Qualifications:
- Bachelor's degree or higher from an accredited school of nursing
WORK EXPERIENCE
- Five (5) years clinical nursing experience which includes two (2) years care management experience, telehealth preferred
- Chronic disease management experience preferred
- RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 90 days or
- RN-Temp - Registered Nurse - Temporary State Licensure within 90 days and
- BLS - Basic Life Support (AHA) and
- Magnet - ANCC Recognized Certification -- in applicable specialty area, to obtain within six months of hire/transfer, i.e. Case Management (Certified Case Manager (CCM), Accredited Case Manager (ACM), Registered Nurse-Board Certified (RN-BC), Certified Diabetes Care and Education Specialist (CDCES), etc. within 6 months
KNOWLEDGE, SKILLS, AND ABILITIES
- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
- Sufficient proficiency in speaking, reading, and writing the English language 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
- Demonstrates ability to prepare and present departmental presentations
- Demonstrates strategic and analytic thinking to address gaps in care
- Demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach
- Ability to determine appropriate course of action in more complex situations
- Responds promptly to emails and phone calls from care team
- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations.
- Demonstrates overall skill in caseload management
- Strong assessment, and organizational skills as evidenced by capacity to prioritize multiple tasks and role components
- Ability to handle difficult situations involving patients, employees, physicians or others in a professional manner.
- Proficient computer skills including data entry, retrieval and report generation; experience documenting in an Electronic Medical Record
- Knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local and federal programs.
- Exhibits a strong knowledge of the teaching principles of health care information to adult and geriatric populations
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 (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.
- On Call* No
TRAVEL**
**Travel specifications may vary by department**
- May require travel within the Houston Metropolitan area No
- May require travel outside Houston Metropolitan area No
Company Profile:
Houston Methodist is one of the nation’s leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Equal Employment Opportunity
Houston Methodist is an Equal Opportunity Employer.
Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law. VEVRAA Federal Contractor – priority referral Protected Veterans requested.
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