Care Manager II - Case Management

CHRISTUS Santa Rosa Hospital - New Braunfels (CSRH-NB), nestled in the heart of downtown New Braunfels, is a full-service, 94‑private bed facility that continues to expand to meet the needs of New Braunfels. Innovative equipment and procedures are utilized, including an Outpatient Imaging Center, orthopedic and surgical services, rehabilitation, a renovated birthing center, 24/7 neonatal coverage, emergency care, wound care/hyperbaric center, 3D mammography, and comprehensive heart care, from diagnostics to open‑heart surgery.

The Care Manager (CM) II works in collaboration with the patient/family, physicians, and multidisciplinary team members to ensure patient progression through the continuum of care and to develop a plan of care for each assigned patient from admission through discharge. The CM is responsible for identifying, initiating and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, and length of stay management.

Support and expertise are provided through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Care Coordination and Discharge Planning are both responsibilities of this role. The CM assesses and responds to patient/family needs by coordinating efforts of other team members and identifies and resolves barriers that hinder effective patient care. The CM adheres to departmental and organizational goals, objectives, standards of performance, policies and procedures, and continually assures regulatory compliance.

• Meets expectations of the applicable OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• Coordinates the integration of case management functions into the patient care and discharge planning processes in collaboration with other hospital departments, external service organizations, agencies, and healthcare facilities.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as resource, provides support, and advocates on behalf of the patient related to treatment decisions and end of life issues.
• Closely monitors patient length of stay in regard to the geometric mean length of stay and communicates/collaborates with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Implements and monitors the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Proactively identifies and resolves delays and obstacles to discharge.
• Uses advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Interviews patients/families to obtain information about social, emotional, and financial factors which impact health status to develop comprehensive discharge planning assessment and care plan.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post‑acute level of care needs and options including:
• Acute Rehabilitation Placement
• Nursing Home or Skilled Nursing placement
• Psychiatric or Substance Abuse placement
• New Dialysis
• Child/Adult/Domestic Abuse
• Home Health/Hospice Referrals
• Legal issues (adoptions, guardianship)
• Assistance with Advance Directives
• Community Resource needs
• Financial Issues/Funding options
• DME Referrals and Coordination
• Social Determinants of Health
• Initiates discharge planning at the time of admission and makes post‑hospital service referrals based upon information gathered during assessment and interactions with physicians, multidisciplinary care team, and payors as indicated.
• Acts as patient advocate by negotiating for, and coordinating, resources with payors, agencies, and vendors.
• Ensures that all elements…