Hospital Case Manager

General Summary

The Hospital Case Manager (HCM) focuses on concurrent review of GMG MC patients (members) in the hospital and facility setting. Utilizing nationally recognized care guidelines and the patient’s health plan coverage guidelines, the HCM monitors admissions and continued stays for medical appropriateness. The HCM develops a discharge (DC) plan in coordination with the physician(s), the patient, and the family to promote a safe and timely discharge.

They act as an advocate for members and their families by linking them to educational resources and community resources to support their aftercare. Effective utilization management of healthcare resources is a major function of this role. The HCM participates in the Patient Care Committee Meeting (PCC) and other GMG or Case Management (CM) team meetings to optimize care plans, treatment plans and GMG protocols.

This position has no supervisory responsibilities.

All duties performed will be done accurately and in a timely manner.

• Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
• Ensures customer service is always maintained at the highest level.
• Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
• Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
• Participates in educational programs as needed.
• Bilingual English/ Spanish fluency preferred.
• Other duties as assigned.
• Maintains strictest member and company confidentiality.

• Orients all newly enrolled Managed Care patients to Gonzaba Medical Group.
• Rounds daily on assigned GMG MC Patients in the hospital setting, and at least weekly on those in the SNF setting.
• Utilize nationally recognized care guidelines and the patient’s health plan coverage guidelines to monitor admissions and continued stays for medical appropriateness.
• Assess the medical, physical, psycho-social and transition needs to anticipate the services, equipment, and follow up care that will be needed upon DC.
• Confer with physician(s), patient, and families in developing the transitional or DC plan.
• Demonstrate knowledge of utilization management, care coordination, and current standards of care as a foundation for transition planning activities.
• Enter timely and accurate information into the EMR to document pertinent patient/family communications, referral authorizations and plans.
• Collaborate effectively with other members of the GMG CM team to clearly communicate regarding coverage determinations, authorizations, and any special follow up needed post DC.
• Communicate regularly with the MC Medical Director on patient status, issues, or questions.
• Serve as the clinical liaison with hospital, clinical and administrative staff. Provide information on the clinical authorizations for inpatient / SNF care and milestones achieved toward DC status.
• Attend weekly Patient Care Committee (PCC) as census allows.
• Provide constructive information to patients and families to minimize problems and increase customer satisfaction. Explain and reinforce the physician plan of care.
• Decision‑making is usually based on prior practice or policy, with some interpretation. Must apply individual reasoning to the solution of problems.
• Maintain current knowledge of health plan benefits, health plan contracts and preferred provider network.
• With the assistance of other members of the GMG MC teams, guides physicians in their awareness of preferred contracts, providers, and facilities.
• Perform Clinical High Risk Home Visits as assigned.
• This position will require driving a company vehicle or a personal vehicle; therefore, employees must successfully complete a motor vehicle history check, possess, and maintain a current valid Texas Driver License, and proof of current insurance to be subject for mileage reimbursement.

Minimum high school education or equivalent. Active, unencumbered Registered Nurse with an associate degree or must be state‑licensed practical nurse required. BS in nursing preferred.…