Case Manager (RN) Utilization Review Telecommute
About the position At Houston Methodist, the Case Manager (CM) position is a registered nurse (RN) responsible for comprehensively planning for case management, which includes care transitions and discharge planning of a targeted patient population on a designated unit(s) and/or service lines. 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 position holds joint accountability with the social worker 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.
Responsibilities
- Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner.
- Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care.
- Uses a structured format for regular communication with patients and families.
- Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.
- Assesses all patients timely and thoroughly.
- Participates in daily Care Coordination Rounds (CCR), and identifies, communicates barriers to efficient patient throughput.
- Supports patients and families in preventing/resolving clinical or ethical issues.
- Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interprofessional health care team, as well as patient and family, on complex discharges.
- Maintains ownership of the discharge planning process on assigned units.
- Initiates and facilitates referrals for home health care, hospice, and durable medical equipment.
- Consults with Social Worker Case Manager to assess psychosocial needs associated with transition to alternative levels of care, ensuring discharge disposition is to the appropriate level.
- Facilitates transfers.
- Modifies care based on continuous evaluation of the patient's condition, demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach.
- Documents accurate assessment and interventions efficiently and effectively.
- Plans for routine discharge and elevates emergent situations.
- Manages usual patient assignment and other unit demands and anticipates/plans for potential problems.
- Focuses on discharge domain by contributing to department and hospital targets for quality, patient satisfaction and safety measures.
- Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using nationally recognized screening guidelines.
- Manages assigned patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
- Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay.
- Participates in denial mitigation activities to ensure appropriate reimbursement for services rendered.
- Contributes to meeting department and hospital financial target, with focus on length of stay.
- Utilizes resources with cost effectiveness and value creation in mind.
- Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.
- Identifies areas for improvement based on understanding of evidence-based practice literature.
- Initiates evidence-based practice/performance improvement projects based on these observations and offers solutions by participating in unit projects and 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.
Requirements
- Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
- Bachelor's degree preferred.
- Three years hospital nursing clinical experience.
- Case management experience preferred.
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