Certified Case Manager (RN) - Transition in Care (Medical Center - On-site)

At Houston Methodist, the Case Manager (CM) Certified position is a registered nurse (RN) responsible for comprehensively planning for case management of a targeted patient population on a designated unit(s) and/or service line. This position works with the physicians and interprofessional healthcare team to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes. The CM Certified position holds joint accountability with social workers for discharge planning and continuity of care and assures that admission and continued stay are medically necessary, communicating clinical information to payors to ensure reimbursement. In addition to performing the duties of a CM, this position helps drive change by identifying areas where performance improvement is needed, e.g., day-to-day workflow, education, process improvements, patient satisfaction.

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates with the physician and all members of the interprofessional healthcare team to facilitate care for designated assignment; monitors the patient's progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective.

• Serves as a preceptor and implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. Serves a resource for department and hospital. Provides education to physicians, nurses, and other healthcare providers on case management topics.

• Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Initiates contributions towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance. Identifies when services no longer meet InterQual/Milliman 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, and informs management of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage.

• Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborate with team to recommend opportunities for process improvement.

• Plans for routine/difficult discharge and anticipates/prevents and manages emergent situations. Facilitates timely:
  - Assessment and intervention to prevent or reduce readmission
  - completion of treatment plan and discharge plan
  - modification of plan of care, as necessary, to meet the ongoing needs of the patient
  - assignment of appropriate levels of care
  - completion of all required documentation in designated EMR and applications or programs
  - elimination of discharge barriers

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Documents assessment and interventions efficiently and effectively. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge.

• Performs post-discharge review by analyzing the inpatient record to ensure that compliance with quality indicators are met. Intervenes and takes appropriate action to foster real-time compliance with CMS guidelines and other performance measures associated with certification programs and other regulatory, national, regional or locally- sponsored quality programs. Provides reports, as needed, to appropriate parties showing:
  - compliance with established governmental and/or institutional rules and regulations
  - analysis of problematic areas, and
  - actions taken to improve compliance

• Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.

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

FINANCE ESSENTIAL FUNCTIONS

• Monitors Length of Stay (LOS) for assigned cases on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Contributes to meeting department and hospital financial targets, with focus on length of stay.

• Manages all patients in Observation Status, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.

• Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, state, and federal agencies. Responds to requests for information, monitors covered days, initiates review to assure that all days are covered and reimbursable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Identifies opportunity for practice changes. Offers 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 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 in nursing

• Master's degree preferred

WORK EXPERIENCE

• Five years hospital clinical nursing experience which includes two years in case management

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