Complex Case Manager
Company: Memorial Hermann Health System
Posted on: July 22, 2021
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
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.
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
Education: Bachelors of Science in Nursing (BSN) or
Social Work (MSW) required; Masters degree preferred
- 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
- Minimum three (3) years of experience in hospital-based nursing
or social work.
- Excellent interpersonal communication and negotiation
- Demonstrated leadership skills
- Strong analytical, data management and PC skills
- Current working knowledge of discharge planning, utilization
management, case management, performance improvement and managed
- 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
- 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.
- 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
- 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
- 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,
- 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
- 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
- Completes Utilization Management and Quality Screening for
- 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
- 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
- Meets directly with patient/family to assess needs and develop
an individualized continuing care plan in collaboration with
- 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
- Refers appropriate cases for social work intervention based on
- 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
- 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
- Collects, analyzes and addresses variances from the plan of
care/care path with physician and/or other members of the
- Collects delay and other data for specific performance and/or
outcome indicators as determined by Director of Case
- 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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