Case Manager - Case Management

The Woodlands Hospital, The Woodlands, Texas
Dec 06, 2017
Dec 28, 2017
Case Management
Contract Type
Full Time
Case Manager - Case ManagementThe Woodlands Hospital

Job Description
The purpose of the Case Manager I position is to support the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation and discharge planning functions.
The Case Manager I is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
• Facilitation of precertification and payor authorization processes
• Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
• Application of process improvement methodologies in evaluating outcomes of care
• Support and coaching of clinical documentation efforts and serving as a clinical resource for coders ensuring that documentation accurately reflects severity of illness and intensity of service
• Coordinating communication with physicians.


Current and valid license to practice as a Registered Nurse (ADN or BSN) in the state of Texas. Professional certification as a Case Manager required within two years of employment as a Case Manager I Three years clinical experience in clinical practice area to which assigned. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement Understanding of pre-acute and post-acute venues of care and post-acute community resources. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families. Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

Coordinates/facilitates patient care progression throughout the continuum. Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: Completion and reporting diagnostic testing; Ensures completion of treatment plan and discharge plan; Ensures modification of plan of care, as necessary, to meet the ongoing needs of the patient; Ensures communication to third party payors and other relevant information to the care team; Assignment of appropriate levels of care; Ensures completion of all required documentation in MIDAS screens and patient records Ensures collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Completes Utilization Management and Quality Screening for assigned patients. Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Department standards. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. Refers cases and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated. Communicates with Resource Center to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. Uses quality screens to identify potential issues and forwards information to Clinical Quality Review Department. Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care. Manages all aspects of discharge planning for assigned patients. Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with physician. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation. Ensures and maintains plan consensus from patient/family, physician and payor. Refers appropriate cases for social work intervention based on Department criteria. Collaborates/communicates with external case managers. Initiates and facilitates referrals through the Resource Center for home health care, hospice, medical equipment and supplies. Documents relevant discharge planning information in the medical record according to Department standards. Facilitates transfer to other facilities as appropriate. Actively participates in clinical performance improvement activities. Assists in the collection and reporting of resource and financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data. Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Case Management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff. Other duties as assigned.

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