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Ambulatory Case Manager, multiple locations

Company: Memorial Hermann Health System
Location: Houston
Posted on: January 15, 2021

Job Description:

At Memorial Hermann, we're about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.Job SummaryMemorial Hermann is offering a variety of locations for Ambulatory Care Managers interested in full-time opportunities throughout Greater Houston. To make it easier for your application to be reviewed and considered for open positions across the system, we're asking all Ambulatory Care Manager candidates interested in working at Memorial Hermann to apply to this job posting. When you apply and list your preferred location, our Recruitment Team will match your preferences with open positions to expedite the application process.At Memorial Hermann, we remain committed to delivering extraordinary patient care. Under our new Clinical Care Redesign effort, Acute Case managers, Ambulatory Care Managers and Transitional Care Managers are part of the team who ensure every patient who walks through our doors receives an exceptional end-to-end patient care experience. The aim of case management is to assist staff, patients and doctors in effectively caring for patients throughout the continuum of care.We invite you to find your fit and a new challenge in a fast-paced, dynamic environment. Apply today to learn more and see where you belong.The Ambulatory Care Manager (ACM) is responsible for providing care management services and support to an assigned population with the purpose of improving health outcomes via a coordinated approach. The Ambulatory Care Manager works in collaboration and continuous partnership with patients and their family members, as well as clinic, hospital and post-acute partners, along with community resources, to achieve the desired outcomes. Using a defined process, the Ambulatory Care Manager, identifies patients through risk stratification, establishes care plans and goals and coordinates care and services through the continuum of care with the goal of enhancing patient health and well- being, improving adherence to health programs, and reducing health care costs. Job DescriptionMinimum QualificationsEducation: Registered Nurse (RN)or Social Worker (LMSW)Licenses/Certifications: Registered Nurse (RN)or Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) with active license in the state of TexasExperience / Knowledge / Skills:* Experience in care/case management, chronic disease management or population health preferred* At least two (2) years of experience in care coordination and planning or other related area* Experience working in interdisciplinary teams* Excellent computer skills* Effective oral and written communication skills* Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of "we advance health" through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.Principal Accountabilities* Provides primary care management interventions to identified members enrolled in the Health Management programs.* In conjunction with payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination.* Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.* Provides proactive outreach to members to include telephonic, internet, or face-to-face encounters.* Works cohesively with other health management disciplines to assist members in problem-solving potential issues related to financial and psychological barriers, as well as problems with the overall system of care.* Increases continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.* Manages effective transitions in care by facilitating warm hand-offs and closure of gaps in care.* Promotes timely access to appropriate care and promote effective and efficient utilization of clinical resources.* Promotes adherence to an established plan of care.* Increases utilization of primary care services within an established network.* Reduces emergency room utilization and hospital readmissions via a comprehensive approach.* Increases patients' ability for self-management and shared decision-making.* Increases comprehension and health literacy through appropriate education.* Provides medication management, including comprehensive medication review and make recommendations to primary care provider for medication changes based on evidence-based protocols.* Provides chronic disease and self-management education and support.* Connects patients to relevant community resources necessary to support health and well-being.* Coordinates warm hand-off to member's primary care provider upon successful completion of the program.* Directs and participates in the development and implementation of member care policies and protocols in order to provide advice and guidance in handling special cases or member needs.* Makes referrals to other Health Management team members as necessary to promote effective care coordination services.* Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.* Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.* Other duties as assigned.

Keywords: Memorial Hermann Health System, Houston , Ambulatory Case Manager, multiple locations, Executive , Houston, Texas

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