Work Shift: DAY
Work Week: Weekends & Weekdays
A Case Manager II (CM II) comprehensively plans for case management of a targeted patient population on a designated unit(s). Works with the physicians and multidisciplinary care team to facilitate efficient quality care and achievement of desired treatment outcomes. Holds joint accountability with social worker for discharge planning and continuity of care. Assures that admission and continued stay are medically necessary and communicates clinical information to payers to ensure reimbursement.
- Identifies leadership opportunities for professional growth of peers.
- Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner, listens and responds to the ideas of others.
- Implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. May include preceptorship.
- Uses downtime efficiently, aware of team members’ workload, consistently offers assistance, and responds positively to requests for assistance from other team members.
- Contributes to meeting departmental financial target on scorecard, with focus on length of stay.
- Secures reimbursement for hospital services by communicating medical information required by all 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.
- Manages all patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
- Modifies care based on continuous evaluation of the patient’s condition, demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach.
- Plans for routine discharge and anticipates/prevents and manages/elevates emergent situations. Specific focus given to discharge plan and elimination of barriers.
- Contributes to meeting departmental targets for quality and safety measures on scorecard.
- Uses a structured format for regular communication with patients and families.
- Manages usual patient assignment and other unit demands, completes responsibilities in timely manner with accurate documentation, organizes multiple priorities and anticipates/plans for potential problems.
- Reports “near misses” as well as errors promptly and consistently to improve systems and processes and identify trends.
- Collaborates with staff from the interdisciplinary team concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs.
- Implements unit and hospital initiatives to achieve National Patient Safety Goals.
- Identifies opportunity for practice changes. Researches the change and presents options to shared governance and leadership.
- Assures that designated core measures are met in providing care.
- Maintains individual competencies around critical Case Management functions including; payer rules and regulations, evidence-based level of care criteria sets, and assessment and discharge planning methods.
- Serves as a unit-based leader for comprehensive case management activities including assessing all patients and leading team to set discharge plan, participating in daily Care Coordination Rounds, and identifying and leading resolution to barriers of efficient patient throughput.
- Uses clinical expertise and high risk screening tools to identify need for case management and/or social work intervention. Screening is accomplished by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes.
- Completes full assessment based on the case management high-risk screening tool.
- Continuously reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning.
- Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay.
- Documentation should reflect, completed patient screening/assessment and reassessment upon admission and concurrently as needed. This should be documented in MethOD.
- Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interdisciplinary team, as well as patient and family, on complex discharges. Maintains ownership of the discharge planning process on assigned units.
- Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using InterQual Hospital Severity of Illness and Intensity of Service Criteria or Milliman Care Guidelines. Standard for initial review is within 24 hours of entry or next working day. Standard for concurrent clinical reviews is every 48 hours and no more than 72 hours.
- Denial management: identifies when services no longer meet InterQual/ Millman l criteria, initiates discussion with attending physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from the physician advisor, if needed, informs supervisor of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage.
- Establishes mutual educational goals with patient and family, provides appropriate resources, incorporating planning for care after discharge.
- Supports patients and families in preventing/resolving clinical or ethical issues.
- Contributes to meeting target for patient satisfaction on scorecard, with focus on discharge domain.
- Uses knowledge of levels of care to ensure discharge disposition is to the appropriate level and facilitates transfers. Initiates and facilitates referrals for home health care, hospice, and durable medical equipment. Consults Social Worker to assess psychosocial needs associated with transition to alternative levels of care.
- Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan.
- Provides education to unit-based physicians, nurses, and other healthcare providers on any case management topics.
- Identifies and presents areas for improvement in patient care or unit operations and offers solutions by participating in unit projects and activities.
- Supportive of change initiatives. Adapts to unexpected changes.
- Identifies areas for improvement based on understanding of evidence-based practice literature. Initiates evidence-based practice/performance improvement projects based on these observations.
- Identifies own learning needs, consults with healthcare team experts and seeks continuing education opportunities to meet those needs.
This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.
Bachelor’s degree in Nursing; may consider ADN with additional relevant experience
If BSN prepared, 2 years RN experience in an acute care Hospital setting required; and
18 months of Case Management experience required
If ADN prepared, 2 years RN experience in an acute care Hospital setting required; and
3 years of Case Management experience required
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
Registered Nurse with current Texas license
American Heart Association BLS preferred
Magnet recognized Case Management Certification preferred
SPECIAL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
- Must maintain level of professional contributions & competencies as defined in Clinical Career Path program guide.
- Knowledge of Medicare, Medicaid and Managed Care requirements (acquired within 6 months of hire)
- Works independently with minimal supervision
- Strong assessment, organizational and problem solving skill
- Knowledge of community resources (acquired within 6 months of hire)
- Knowledge of health care financial and payer issues, and eligibility for state, local and federal programs (acquired within 6 months of hire)
- Computer skills
- Advanced oral and written communication skills
- Collaboration, negotiation, and mediation skills
- Time management and prioritization skills
- Critical thinking
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.
Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers nearly 200 beds, 16 operating rooms and over 1300 employees, with access to the most innovative medical and surgical care available, including robotic and minimally invasive surgery, full-spectrum heart care, state-of-the-art imaging, cancer care, labor and delivery with a level II neonatal ICU, neurology and neurosurgery, orthopedics and sports medicine, outpatient rehabilitation and 24/7 emergency services.