At Houston Methodist, the Case Manager PRN (CM) position is a licensed registered nurse (RN) who comprehensively plans for case management of a target patient population on a designated unit(s). This position works with the physicians and interprofessional health care team to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes. The CM PRN holds joint accountability with social worker for discharge planning and continuity of care and assures that admission and continued stay are medically necessary and communicates clinical information to payors to ensure reimbursement. The CM PRN 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 health care team to facilitate care for designated case load; 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; facilitates timely: - completion and reporting of diagnostic testing; - 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 EPIC and MIDAS

　　Serves as a preceptor, as appropriate, and implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. Serves a resource for case management and social work resources and needs for the department and the hospital.

　　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/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, 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.

　　QUALITY/SAFETY ESSENTIAL FUNCTIONS

　　Documents assessment and interventions efficiently and effectively.

　　Plans for routine/difficult discharge and anticipates/prevents and manages emergent situations. Specific focus given to discharge plan and elimination of barriers.

　　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 case load on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Contributes to meeting departmental financial target on scorecard

　　Manages all patients in Observation Status, daily, 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, 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.

　　GROWTH/INNOVATION ESSENTIAL FUNCTIONS

　　Provides education to unit-based physicians, nurses, and other healthcare providers on any case management topics.

　　Identifies opportunity for practice changes. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.

　　Identifies and presents areas for innovation, efficiency and improvement in case management or department operations using evidence-based practice literature. Completes and updates the individual development plan (IDP) 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

　　Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certificates, Licenses and Registrations section.WORK EXPERIENCE

　　Three (3) years hospital clinical nursing experience which includes two (2) years in case managementLICENSES AND CERTIFICATIONS - REQUIRED

　　RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 90 days or

　　RN-Temp - Registered Nurse - Temporary State Licensure within 90 days

　　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.

　　Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components

　　Knowledge of Medicare, Medicaid and Managed Care requirements

　　Comprehensive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local and federal programs

　　Comprehensive 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.

　　Ability to work independently

　　Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components

　　Demonstrates critical thinking and makes decisions using evidence-based analytical approach in interactions with physicians, payors, and patients and their families

　　Well versed in computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint and Word)

　　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* YesTRAVEL**

　　Travel specifications may vary by department

　　May require travel within the Houston Metropolitan area Yes

　　May require travel outside Houston Metropolitan area No

　　Company Profile:

　　Houston Methodist The Woodlands Hospital is committed to leading medicine in Montgomery County and the north Houston region by delivering the Houston Methodist standard of exceptional safety, quality, service and innovation. The growing campus offers 293 beds and access to the most innovative care. In January 2022, the hospital opened Healing Tower – a $250-million expansion project that added 106 beds, focused on medical/surgical and women’s services and nine operating rooms. It also included the expansion of the endoscopy center, emergency department and diagnostic imaging department.

　　Houston Methodist The Woodlands is recognized as a comprehensive stroke center, an orthopedic center of excellence by DNV, designated as a Level III neonatal intensive care unit, and has achieved Magnet Designation for nursing excellence from the ANCC. Houston Methodist The Woodlands is also ranked No. 1 nationally out of 148 members in the Complex Care Medical Centers cohort to be recognized for demonstrating excellence in delivering high-quality care based on the 2022 Vizient Quality and Accountability Ranking.

　　Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.

　　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 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.