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Complex Case Manager

Company: Memorial Hermann Health System
Location: Houston
Posted on: July 22, 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 Summary
The Complex Case Manager will work with a defined referral based complex patient population across the healthcare system to coordinate effective, timely discharges and post acute care transitions. Will work in conjunction with the local case management team and System leadership to develop organization-wide approaches to problem solving, tracking and managing extremely complicated complex cases. Will identify and analyze current systems and variances to identify opportunities for improvement. Will identify post acute services for potential coordination and contracting to support case load volumes. Works to promote quality of care through collaboration with all service team members, physicians, patients and families. Works with the Campus financial leadership to track and monitor related expenses to budget. Accountable for a designated patient caseload that is of the highest complexity and resource intensity. Plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Works in partnership with the Complex Care Management Social Worker to address identified social determinant needs. Hybrid work environment. Will require travel to individual Memorial Hermann campuses to perform necessary coordination/assessment activities.

Job Description

Minimum Qualifications

Education: Bachelors of Science in Nursing (BSN) or Social Work (MSW) required; Masters degree preferred

Licenses/Certifications:

  • 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
  • Case Manager Certification required


Experience / Knowledge / Skills:
  • Three (3) years experience in utilization management, case management, discharge planning or other cost/quality management program.
  • Minimum three (3) years of experience in hospital-based nursing or social work.
  • 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 and managed care reimbursement
  • Understanding of pre-acute and post-acute venues of care and post-acute community resources
  • 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
  • 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
  • Oversees the management of specific patient populations across the continuum focusing on high-risk, high-cost patients. Serves as a resource to the multidisciplinary team for the management of complex patients.
  • Works with physician leadership and the multidisciplinary team for defined patient populations to develop clinical pathways, continuum care management programs, measurement and feedback of performance indicators for cost, quality and service and patient satisfaction.
  • Serves as the primary information resource for case management staff, payors, physicians, other healthcare team members and customers (skill areas include: regulatory requirements, pathway development/implementation, ethics/healthcare law, clinical skill, etc.)
  • Facilitates learning experiences of healthcare team members, conducts in-services, and/or serves as a resource for pathways. Participates in teaching CM Modules.
  • Assumes delegated activities from the Director as needed.
  • 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 management.
  • Proactively identifies/resolves issues impeding diagnostic, treatment progress and 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: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication to third party payors and other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in MIDAS 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 as needed.
  • Uses quality screens to identify potential issues and forwards information to Clinical Quality Review Department.
  • Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
  • Manages all aspects of discharge planning for assigned patients.
  • Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with physician.
  • Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation.
  • Ensures/maintains plan consensus from patient/family, physician and payor.
  • Refers appropriate cases for social work intervention based on Department criteria.
  • Collaborates/communicates with external case managers. Initiates and facilitates referrals through the Resource Center for home health care, hospice, medical equipment and supplies.
  • Facilitates transfer to other facilities as appropriate.
  • Actively participates in clinical performance improvement activities.
  • Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals.
  • Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.
  • Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team.
  • Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Case Management
  • Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning).
  • Initiates and leads the development, implementation, evaluation and revision of clinical pathways and other Case management tools as a member of the clinical resource/team.
  • Assists in compilation of physician profile data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction and quality indicators (e.g., readmission rates, unplanned return to OR, etc.)
  • Acts as preceptor/mentor to new hires.
  • Assists in developing orientation schedule and helps identify individual needs for learning.
  • 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 , Complex Case Manager, Other , Houston, Texas

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