Nurse Manager, Case Management
Location: United States - Texas - Houston
Industry: Healthcare / Health Services - Social Services / Mental Health
Job Category: Medical / Health - Nurse Leadership
Under direction is responsible for functional and operational aspects of the Case Management / Social Work Department, an integrated, multi-disciplinary department which supports caregivers to provide the highest quality, most clinically appropriate care to patients and while promoting the most cost-effective utilization of the hospital?s resources. Provides leadership, guidance and direction to staff. Maintains accountability for level of unit performance and results.
Responsible for quality, functional excellence and contribution to accomplishment of strategic and operational objectives. Accountable for the design, implementation, training, and resources for the Care Management system for the organization. Possesses the ability to interact with corporate and hospital administrators, medical staff, and defined customers related to the Care Management system. Responsible for the Care Management reporting system to ensure organization priorities are appropriately addressed in all facilities.
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 20 %
1. Provides the leadership to have a competent and satisfied employee group by doing timely performance appraisals, providing development and mentoring of subordinates and staff. Hires, coaches, trains, disciplines and terminates staff as necessary. (EF)
SERVICE - 20 %
1. Plans and organizes day-to-day operations, schedule and activities of the work group. Sets priorities and functional standards; gives direction to staff as necessary. (EF)
2. Makes and executes decisions within delegated authority. Surfaces issues to management for resolution as appropriate. Participates in resolving issues outside delegated scope of authority. (EF)
QUALITY/SAFETY - 30 %
1. Supports maximization of Care Management system utilization. Recommends appropriate uses for the Care Management system. Collaborates with departmental management and/or staff, Information Technology (IT) personnel, other functional areas, and software vendors as appropriate to determine information needs and ensure timely information updates. (EF)
2. Conducts special studies, performs informational analysis, and develops special reports as requested through system tools and resources. Generates reports to identify trends and opportunities for process improvement. Prepared data for presentation.
Develops auditreports to identify quality issues and to identify areas for enhanced staff training. (EF)
3. Manages Utilization Management (UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals. Collaborates with the Director of Case Management/Social Work on Criteria and Policy Key Development, and the Prior Authorization List. Collaborates with Physician and Nursing leaders and external entities to develop, implement and evaluate UM program policies as directed and ensures UM programs are consistent with national accreditation guidelines.
4. Provides leadership to ensure operational effectiveness and efficiency of retrospective UM and medical claims functions to meet and exceed service-level goals and contract requirements. Oversees the quality assurance and quality improvement processes related to retrospective UM and medical claims programs. Collaborates with medical and clinical leadership to implement new processes for enhancing service levels. (EF)
FINANCE - 20 %
1. Participates in planning, budgeting and general management efforts for the department of which the unit is a part and stays within budget. (EF)
GROWTH/INNOVATION - 10 %
1. Evaluates departmental procedures and operations as they relate to information technology and recommends changes to improve efficiency and effectiveness as appropriate. Ensures the effective use of departmental information system by coordinating initial training for new users and ongoing training departmental staff of system upgrades, changes, and new functions as necessary. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
o For RNs
Bachelor?s of Science in Nursing (BSN) degreerequired for RN applicants; Masters preferred
o For Social Workers
Bachelor?s degree and Masters degree in Social Work (MSW) required for Social Work applicants.
o Five years experience in inpatient case management, social work or utilization management department or in the managed care/payer environment.
o Management Experiencepreferred.
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
o For RNs
Must have valid Texas RN licensure.
o For Social Workers
Licensed Masters Social Work (LMSW) required
Licensed Clinical Social Work (LCSW) preferred
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
o Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations.
o Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
o Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.
o Leadership skills
o Computer literacy
o Advanced written and oral communication skills
o Excellent analytical skills
o Advanced negotiation and mediation skills
o Advanced time management and prioritization skills
o Expert collaboration skills
Security Clearance Required: No
Visa Candidate Considered: No
Full-time Benefits - Full
Relocation Assistance Available - Yes
Commission Compensation - No
Bonus Eligible - No
- 5+ to 7 years experience
Seniority Level - Mid-Senior
Management ExperienceRequired - No
Minimum Education - Bachelor's Degree
Willingness to Travel - Occasionally
- Five years experience in inpatient case management, social work or utilization management department or in the managed care/payer environment