Case Manager Advanced

At Houston Methodist the Case Manager (CM) Advanced position is a registered nurse (RN) responsible for promoting the achievement of optimal clinical and resource outcomes accountable for a designated assignment that is considered more complex and resource intensive. This position has achieved an expert level at all the objectives delineated in the Case Manager and Case Manager Certified job roles and is responsible for facilitating appropriate lengths of stay (LOS) and reimbursement for all hospital admissions in accordance with set goals and objective. The CM Advanced position assures that admission and continued stay are medically necessary communicating clinical information to payers to ensure reimbursement. The Advanced CM position analyzes variances to identify opportunities for improvement and acts as the key information and education resource for the interprofessional health care team. This position promotes and maintains compassionate quality of care through collaboration with all service team members patients and families and works with the leadership team for special project activities related but not limited to throughput readmissions and utilization management to align with the visions and goals of the department and organization. The CM Advanced position will lead projects or perform specialized responsibilities as a regular part of their normal job responsibilities.

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

• Actively supports the organizations vision fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Promotes a positive work environment and leads the team to be a dynamic teamfocused work unit that actively helps one another to achieve optimal department results. Acts as a role model to team members exemplifying effective communication skills. Collaborates with all members of the patient care team by actively communicating and reporting pertinent patient care information and data in a comprehensive manner.

• Works with physician leadership and the interprofessional healthcare team for defined patient populations to develop clinical pathways continuum care management programs measurement and feedback of performance indicators for cost quality and service and patient satisfaction.

• Serves as the primary information resource for case management staff payors physicians other healthcare team members and customers. Acts as a formal preceptor/coach for new case management employees. Develops skills of team members and continually assists with improving skills performance and outcomes. Provides feedback to management on team member performance and conduct.

• Collaborates with leadership team on recruitment and retention strategies and key initiatives to improve employee relations participation and engagement. Initiates improvement of department scores for employee engagement i.e. peertopeer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a leader for comprehensive case management activities including assessing all patients and leading team to set discharge plan participating in daily rounds or discussions identifying and leading resolution of barriers to efficient patient throughput.

• Continuously reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. Mentors others regarding specialty populations.

• Independently handles resolution of complex problems and issues. Serves as escalation support for novice staff. Implements and leads initiatives to improve patient and family satisfaction related to discharge question(s) on HCAHPS.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Identifies need for case management and/or social work intervention and implements strategies that improve care coordination metrics (LOS reduction discharges before 11am and readmission reduction) by using clinical expertise and highrisk screening tools.

• Actively participate in systemwide projects regarding Case Management related topics such as length of stay reduction readmission prevention utilization management denial mitigation and appeal resolution. Identifies opportunities for process improvement to improve the quality of case management and social work documentation providing recommendations to meeting department and hospital targets for quality and safety. Works with the department leadership to create and/or enhance current operational and documentation of efficiencies to improve the quality of information in the medical record.

• Performs chart audits to assess compliance with departmentspecific tasks and documentation. Tracks and trends performance and reports to department leadership.

FINANCE ESSENTIAL FUNCTIONS

• Oversees the management of specific patient populations across the continuum focusing on highrisk highcost patients. Takes leadership role in collaborating with employees to secure reimbursement for hospital services. Collaborates with department leadership on costreduction strategies. Leads efforts to ensure appropriate capture of avoidable and excess days. Reports trends to department leadership team.

• Functions as resource to department staff in communicating medical information required by external review entities managed care contractors insurers fiscal intermediaries state and federal agencies. Collaborates with the appropriate resources to mitigate denials.

• Collaborates with department leadership on efforts to reduce length of stay (LOS) including serving as the resource to staff on proactively identifying and assessing difficult discharges timely escalation and progressive care coordination for next level of care arrangement and transition.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Expands own knowledge and serves as instructor in continuing education or formal program and expert consultation; coaches staff to grow in knowledge abilities skills and attitudes. Reads and leads critique of evidencebased practice literature in case management and related disciplines. Identifies plans and implements education for the unit and service line in collaboration with team members and interprofessional partners.

• Fulfills role of leadership on at least one hospital or systembased committee. Seeks opportunities to identify selfdevelopment needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be allinclusive; 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

• Bachelors degree or higher in nursing

• Masters degree preferred

WORK EXPERIENCE

• Seven years hospital clinical nursing experience which includes five years in case management

LICENSES AND CERTIFICATIONS REQUIRED

• Health ServicesRN Registered Nurse Texas State Licensure and/or Compact State Licensure within 60 days OR
• Health ServicesRNTemp Registered Nurse Temporary State Licensure within 60 days AND
• Health ServicesMagnet ANCC Recognized Certification Case Managementrelated OR
• ACM Accredited Case Manager (NBCM) National Board for Case Management

KNOWLEDGE SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through ongoing 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 coworkers in a manner consistent with a customer service focus and application of positive language principles

• Ability to work independently and exercise sound judgment in interactions with physicians payors and patients and their families

• Strong assessment organizational and problemsolving skill as evidenced by capacity to prioritize multiple tasks and role components

• Knowledge of community resources health care financial and payer issues Medicare Medicaid and Managed Care requirements and eligibility for state local and federal programs

• Skillspecific areas include: regulatory requirements pathway development/ implementation ethics/healthcare law clinical skill etc.

• Expert knowledge of discharge planning utilization management case management performance improvement and managed care reimbursement

• Understanding of preacute and postacute venues of care and postacute community resources

• Proficient in computer skills of the entire Microsoft Office Suite (Access Excel Outlook PowerPoint and Word)

• Required passage of Interrater Reliability test (IRR)

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ONCALL*
*Note that employees may be required to be oncall during emergencies (ie. DIsaster Severe Weather Events etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

Houston Methodist (HM) is one of the nations leading health systems and academic medical centers. HM 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 metropolitan area. HM also includes an academic institute a comprehensive residency program a global business division numerous physician practices and several freestanding emergency rooms and outpatient facilities. Overall HM employs over 25000 employees. Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.

In 2019 Houston Methodist and its physicians treat more than 6333 international patients from more than 76 countries. Houston Methodist Global Health Care Services consulting and education divisions also provide advisory services and training and development to health care organizations around the world.