Health Solutions Case Manager

At Memorial Hermann we pursue a common goal of delivering high quality efficient care while creating exceptional experiences for every member of our community. When we say every member of our community that includes our employees. We know that when our employees feel cared for heard and valued they are inspired to create moments that exceed expectations while prioritizing safety compassion personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities now and for generations to come we want you to be a part of our team.

Job Summary

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.

Position Overview: We are seeking a skilled and compassionate Workplace Injury Case Manager to join our team. The ideal candidate will have a minimum of 3 years of experience in case management with a strong focus on workplace injuries in a non-subscriber environment. A CCM certification is preferred as we aim to ensure the highest standards of care for our patients.

Key Responsibilities:
➡️Manage and coordinate care for employees with workplace injuries ensuring timely and effective treatment.
➡️Collaborate with healthcare providers employers and insurance companies to facilitate the best outcomes for injured workers.
➡️Conduct comprehensive assessments to develop individualized care plans.
Monitor progress and adjust care plans as necessary to meet the changing needs of patients.
➡️Provide education and support to patients and their families regarding injury management and recovery processes.
➡️Maintain accurate documentation and records in compliance with regulatory requirements.
➡️Utilize technology effectively including Zoom for virtual meetings and Microsoft Office for documentation and communication.
➡️ Leverage experience with non-subscriber programs to enhance case management strategies and improve patient outcomes.

Join a team who shares your dedication to caring for others and each other.
• Advocate for your patients and your colleagues through our Professional Governance Congress model.
• Benefit programs providing resources for dependents include financial & education planning plus employee discounts on a variety of services & products.
• Generous PTO holidays and personal and spiritual holidays to support work-life balance.

Job Description

Minimum Qualifications

Education : Graduate of an accredited school of nursing. Associate of Nursing or Bachelor 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

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.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe caring personalized and efficient experiences to patients and colleagues.
• Other duties as assigned.