Case Manager - Memorial Hermann Health Plan

Unlock Employer Houston, TX Closed
Memorial Hermann Health System is looking for Case Manager - Memorial Hermann Health Plan in Houston, TX. This local job opportunity with ID 3474824 is live since 02/15/2018.
Case Manager - Memorial Hermann Health SolutionsHealth SolutionsJob DescriptionResponsible 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

Minimum Qualifications:

Education: Graduate of an accredited school of nursing (ADN or BSN).

Experience: Three to five years clinical experience

Three to five years experience in a Managed Care environment performing case management.

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

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.

Principle Accountabilities:

  • Demonstrate 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.
  • Analyze referrals to accept or deny individuals according to Case Management procedures.
  • Serve as a means for facilitating patient wellness and autonomy though advocacy, communication, education, and identification of service resources.
  • Help 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.).
  • Present all cases when unable to negotiate an acceptable alternative to the Medical Director for determination.
  • Collect accurate data for system input by using correct coding of diagnoses and/or procedures.
  • Enter data into appropriate system and prepare all written communication to patient and/or provider.
  • Adhere to and apply all Health Solutions policies, procedures, and guidelines appropriately.
  • Achieve an in-depth knowledge of client benefit plan.
  • Act as resource person for Utilization Review staff.
  • Perform other related duties as requested by Supervisor/Director.
  • Process and maintain confidential information according to confidentiality policy.
  • Negotiate fees with non contracted providers and refer to contracting.
  • Maintain a 90% or greater score on the quarterly audit tool.
  • Communicate, collaborate and cooperate with internal and external stakeholders.
  • Adhere to all Compliance/Program Integrity requirements.
  • Comply 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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