Hybrid Case Manager en Nexus Health Systems

POSITION SUMMARY:

The Case Manager is responsible for assessing is responsible for assessing the psychosocial needs of patients and their families, as well as planning, implementing, and evaluating care throughout the healthcare episode. This includes ensuring the delivery of cost-effective, high-quality care within an appropriate length of stay. The role involves managing patient care to prevent fragmentation and duplication of services, while collaborating with physicians and other healthcare team members to address patient-specific and age-related needs. The Case Manager also integrates cost resource management

and quality care into the patient care process.

JOB-SPECIFIC RESPONSIBILITIES:

•    Service

o    Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems

o    Upholds the Standards of conduct and corporate compliance

o    Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.

o    Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.

o    Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

o    Collaborates effectively with colleagues and other departments to ensure seamless service delivery.

•    Clinical Excellence

o    Assessment and Planning:

    Conduct comprehensive psychosocial, medical, and emotional assessments, collaborating with patients and families.

    Develop and adjust individualized care plans based on medical history, psychosocial needs, and age- specific requirements.

    Monitor patient progress and update care plans to ensure optimal outcomes.

    Apply DRG and InterQual guidelines for appropriate care management and timely discharge.

    Ensure physician documentation supports medical necessity for ongoing treatment.

    Coordinate specialist consultations and diagnostic tests for informed decision-making.

    Address patient education needs to ensure safe discharge and meet learning requirements.

    Maintain updated lists of financial and community resources for all patient age groups.

o    Implementation and Coordination of Care:

    Coordinate seamless implementation of care plans across the healthcare team, minimizing fragmentation and duplication.

    Manage care transitions, ensuring appropriate services at each stage of the healthcare process.

    Conduct ongoing utilization management reviews and refer cases to the Physician Advisor/Medical Director when needed.

    Lead Multidisciplinary Team Conferences within seven days of admission and weekly thereafter.

    Resolve discharge planning and care coordination issues through effective communication across departments.

    Oversee discharge planning, ensuring services and equipment align with patient needs and family preferences.

    Ensure efficient use of medical resources to optimize care and manage costs.

    Document and track suspected abuse or neglect, ensuring compliance with policies.

o    Collaboration with Healthcare Team:

    Collaborate with the healthcare team to address patient-specific needs and align care plans with clinical goals.

    Participate in multidisciplinary rounds to discuss patient progress and adjust care plans.

    Educate and support patients and families on the care process, discharge instructions, and community resources.

    Eliminate service duplication and enhance care continuity by working closely with the healthcare team and family.

    Provide guidance in end-of-life care decisions, respecting patient and family preferences.

    Foster interdisciplinary communication and teamwork for effective care and discharge planning.

    Coordinate with external payors to ensure timely medical management and smooth transitions.

    Support documentation of interventions and outcomes to ensure timely clinical decisions.

•    Patient Experience and Advocacy

o    Advocate for the well-being and rights of all patients, ensuring their voices are heard.

o    Uphold patient privacy and confidentiality, ensuring compliance with relevant standards.

o    Align actions with the organization's mission, values, and strategic goals.

o    Support the organization’s Quality, Risk, and Continuum of Care philosophy in all activities.

o    Provide equitable case management, utilization management, and discharge planning for all patients, regardless of insurance.

o    Develop and maintain comprehensive resource lists for patients and staff, including financial and community resources.

o    Offer relevant community resources to patients and families for discharge placement, DME, home health services, and more.

o    Promote efficient use of medical resources to ensure high-quality care and appropriate cost management.

o    Maintain a safe and secure environment for patients and staff, adhering to safety standards.

o    Ensure proper documentation and follow-up of potential abuse or neglect in compliance with policies.

•    Quality Assurance and Compliance

o    Ensure all activities adhere to healthcare regulations and organizational policies.

o    Participate in quality improvement initiatives to enhance service delivery.

o    Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.

o    Integrate quality care principles into practice, optimizing patient outcomes while following clinical guidelines and best practices.

o    Support cost-efficient care by minimizing unnecessary services and interventions.

o    Monitor patient outcomes to assess care effectiveness and contribute to quality improvement initiatives.

o    Ensure accurate documentation of assessments, care plans, interventions, and progress in compliance with hospital policies and regulatory requirements.

o    Maintain full compliance with healthcare standards and regulations in all patient care and case management activities.

•    Professional Growth and Continuing Education

o    Completes annual education requirements.

o    Maintains competency, as evidenced by completion of competency validation requirements.

o    Maintains competency and knowledge of current standards of practice, trends, and developments.

o    Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.

o    Maintain up-to-date knowledge of relevant healthcare regulations and practices to ensure that the Case Management process remains current and compliant.

•    Finance

o    Promotes stewardship of hospital resources while ensuring quality patient care.

o    Deliver cost-effective care without compromising quality, aligning resources with patient needs and clinical condition.

o    Manage appropriate length of stay, collaborating with the healthcare team to prevent delays and ensure timely discharge.

o    Utilize resources effectively to reduce waste and prevent overutilization.

•    Performs other duties as assigned.

POSITION QUALIFICATIONS:

EDUCATION:

•    Graduate of an accredited School of Nursing with an Associate Degree in Nursing, BSN preferred or Graduate of a Bachelor’s Degree in Social Work (BSW) or Master's degree in Social Work (MSW)

EXPERIENCE:

•    3-5 years experience in acute hospital direct care

•    2-3 years experience in acute hospital case management, utilization management, or discharge planning of complex medical/surgical cases

•    Knowledge of healthcare systems, care coordination, discharge planning, and psychosocial support.

SKILLS:

•    Strong clinical knowledge to assess complex medical and psychosocial conditions.

•    Excellent communication and interpersonal skills for effective collaboration with patients, families, and healthcare teams.

•    Proficient in using electronic health records (EHR) and case management software.

•    Strong critical thinking and problem-solving skills to develop and implement care plans.

•    Ability to manage multiple cases in a fast-paced healthcare setting.

•    Experience with InterQual, Milliman, or other nationally recognized criteria (preferred).

•    Strong analytical, organizational, and time-management skills.

•    Knowledge of professional practice standards and regulatory requirements in managed care and accreditation.

LICENSURE/CERTIFICATION:

•    Registered Nurse, Licensed BSW, Licensed MSW with an active, unrestricted license in the State of Texas.