Case Manager

Description Minimum Qualifications

Education
:
Graduate of an accredited school of professional nursing required;
Bachelors of Nursing preferred,
or graduate of an accredited Master of Social Work program

• Current and valid license to practice as a Registered Nurse in the state of Texas or

• Current and valid license as a Master Social Worker (LMSW) in the state of Texas required, LCSW preferred

• Certification in Case Management required within two (2) years of hire into the Case Manager position

• Three (3) years of nursing or social work experience acute hospital-based preferred, or three (3) years of experience comparable clinical setting (i.e. ambulatory surgery center, infusion/dialysis clinic, Federally Qualified Health Clinic (FQHC), skilled nursing facility, or wound clinic)

• Experience in utilization management, case management, discharge planning or other cost/quality management program preferred

• Excellent interpersonal communication and negotiation skills

• Demonstrated leadership skills

• Strong analytical, data management and PC skills

• Current working knowledge of discharge planning, utilization management, case management, performance improvement, disease or population management and managed care reimbursement

• Understanding of pre-acute and post-acute venues of care and post-acute community resources, physician office routines, and transitional procedures for pre and post acute care. Demonstrated understanding of motivational interviewing and change management

• 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

• Effective oral and written communication skills

• 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 care.

• 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:
  Completes and reports diagnostic testing, Completes treatment plan and discharge plan, Modifies plan of care as necessary, to meet the ongoing needs of the patient, Communicates to third party payors and other relevant information to the care team.

• Assigns appropriate levels of care.

• Completes all required documentation in TQ screens and patient records.

• 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…