HEALTH SOLUTIONS CASE MANAGER
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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.
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.
- 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
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More than a century of patient-centered care. At Memorial Hermann, we are all about advancing health. Yours.