HEALTH SOLUTIONS CASE MANAGER

Responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating options and services required to meet an individual's health needs using communication and available resources to promote quality, cost-effective outcomes.

Job Description

Job Description

Minimum Qualifications

Education: Graduate of an accredited school of nursing Associate of Nursing orBachelor of Nursing

Licenses/Certifications: Current, unrestricted Texas licensure to practice as a Registered Nurse required, CCM certification preferred

Experience / Knowledge / Skills:

• Minimum of three (3) years clinical experience and one (1) to two (2) years experience in a Managed Care environment performing case management
• Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement
• Strong clinical background in nursing or social services
• Knowledge of insurance terminology
• Basic knowledge of computer system
• Excellent verbal and written communication skills
• Ability to perform multiple tasks simultaneously, works under pressure, and meet critical deadlines
• Assertiveness and negotiation skills, which support ability to interact with hospital, discharge planner, physicians and other health care providers
• Exceptional documentation skills
• Ability to work independently, manage time and prioritize projects
• 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

• Demonstrates commitment to Health Solutions behavioral expectations in all interactions and in performing all job duties. Perform job duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety and cost efficiency.
• Analyzes referrals to accept or deny individuals according to Case Management procedures.
• Serves as a means for facilitating patient wellness and autonomy though advocacy, communication, education, and identification of service resources.
• Helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost effective manner in order to obtain optimal value for both the patient and the client.
• Establish/maintain good rapport with provider to obtain necessary information.
• Follow Health Solutions guidelines and procedures to make appropriate referrals relative to individual cases (Physician Review, Stop Loss, etc.).
• Presents all cases when unable to negotiate an acceptable alternative to the Medical Director for determination.
• Collects accurate data for system input by using correct coding of diagnoses and/or procedures.
• Enters data into appropriate system and prepare all written communication to patient and/or provider.
• Adheres to and apply all Health Solutions policies, procedures, and guidelines appropriately.
• Achieves an in-depth knowledge of client benefit plan.
• Acts as resource person for Utilization Review staff.
• Performs other related duties as requested by Supervisor/Director.
• Process and maintain confidential information according to confidentiality policy.
• Negotiates fees with non contracted providers and refer to contracting.
• Maintains a 90% or greater score on the quarterly audit tool.
• Communicate, collaborate and cooperate with internal and external stakeholders.
• Adheres to all Compliance/Program Integrity requirements.
• Complies with HIPAA Regulations
• 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