Case Management Representative

Overview
At Houston Methodist, the Case Management Representative position is responsible for providing clerical assistance and data management support to the case management and social work department to facilitate efficient utilization of resources and discharge planning including referrals management, communication and collaboration with post-acute care providers, access to agencies and other community resources and transportation. This position may perform some secretary duties and performs a wide variety of administrative duties of a higher complexity in support of Case Management operations. In addition, the CM Rep position performs independent actions necessary to provide competent and professional assistance to meet the needs of social workers/case managers and patients. This position also coordinates, oversees, records, and transmits information pertinent to the resource management of patients to next level of care providers.
Houston Methodist Standard
PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.
HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities
PEOPLE ESSENTIAL FUNCTIONS

• Serves as a department resource for questions related to case management activities. Communicates in an active, positive, and effective manner to all interprofessional health care team members. Reports pertinent patient care and family data in a comprehensive and unbiased manner. Performs phone call and communication triage, troubleshoots and routes issues to appropriate individuals, assists in resolution of non-clinical issues as needed

• Facilitates and arranges acquisition of post-acute needs, as directed, and in collaboration with the clinical team. Follows payor/reimbursement practices and regulations that may impact the patient's plan of care

• Provides appropriate and timely communication, update, and documentation to the referring personnel to keep them informed of the status of the request

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

SERVICE ESSENTIAL FUNCTIONS

• Assists the department in distributing required notices, including the Medicare Notice of Discharge to patients, securing signatures on the form from the patient or their legal representative, and answering questions regarding the appeal process

• Distributes the Medicare Notice of Discharges to identified patients, including capturing patient and their legal representative's signatures, answering any questions regarding the appeal process

• Coordinates with the clinical staff to prioritize placement requests. Provides necessary documentation to facilitate post-acute services

• Assists with clerical and clinical functions for patients, physicians, and staff. Provides administrative support as needed, including scheduling follow-up appointments, and confirming the provision or delivery or post-acute services or equipment

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Participates in quality improvement initiatives and collects data for use in department performance improvement as directed. Maintains timelines for follow up and prioritization of department projects and tasks

• Updates and maintains resources, information and database or directories elated to post-acute providers and insurance contacts to facilitate timely communication and coordination as needed

FINANCE ESSENTIAL FUNCTIONS

• Informs social worker/case manager of the patients' available benefits through insurance/managed care provider. Assists in providing community resources/services to uninsured patients as requested Case Management staff

• Participates in reimbursement/certification and authorization-related activities as directed. Documents approvals and authorization numbers from payors. Logs communications and provides information to social workers and case managers, business office/patient access, etc. on insurance/managed care benefits

• Supports and assists with concurrent insurance denials and appeals process, transmission of utilization reviews to insurance companies, coordination of peer discussions as directed by the clinical team. Documents authorization, approvals, and denials

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Maintains awareness of payor/reimbursement practices and regulations that may impact patient's plan of care and confers with care coordinators and social workers to prioritize placement requests

• 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
EDUCATION

• High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

• Associate degree preferred

WORK EXPERIENCE

• Two years of experience in any of the following: service recovery, insurance verification, working with patient information, having patient contact, and/or general health care coordination responsibilities within a healthcare environment

• Previous experience in hospital setting and/or Case Management

License/Certification
LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

KSA/ Supplemental Data
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

• Some knowledge of community resources

• Must be able to operate within a Microsoft Office environment. Proficiency in MS Outlook and MS Word/Excel, knowledge of Medical Terminology

• Excellent telephone, oral and written communication skills, time management and prioritization skills

• Able to learn new skills effectively

• Ability to work independently while collaborating with other team members and exercise sound judgment in interactions with physicians, payors, and patients and their families

• Strong organizational and problem-solving skills

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 Cypress Hospital, scheduled to open in the first quarter of 2025, will be Houston Methodist's ninth hospital and will incorporate the most advanced technology available from the day the doors open. With 100 beds (at our opening; licensed for 276) and a prime location in the heart of the rapidly growing U.S. 290 corridor, the hospital will be equipped with technologically advanced innovations implemented during COVID, many of them designed to make patient communication with physicians, staff and families the very best and most effective in any health care facility. Even though the hospital won't be fully operational until 2025, we have several services and specialties opening in 2024.