Registered Nurse Care Manager - Primary Pediatric in San Antonio, TX

Summary:

This position provides expertise and leadership to insure effective resource management for patient care delivery (Conditions of Participation COP 482.30). Case Managers enhance the continuity of care and cost effectiveness by integrating the functions of case management, resource management, clinical documentation management, and discharge planning (Conditions of Participation COP 482.43). Daily and concurrently involved in the management of inpatient and observation patients by comprehensive assessment, planning, interventions, and evaluations of appropriate level of care. Collaborates with other members of the health care team to ensure the above according to the mission of CHRISTUS Santa Rosa Health Care.

Responsibilities:

• Key driver of throughput process by safe discharge plan
• Daily monitors LOS compared to GMLOS on each patient for reduction in opportunity days to reach LOS ratioLOS: Impacts Medicare GMLOS by managing per Milliman/Interqual Care Guidelines.
• Resource/Utilization Management/appropriateness: Assess assigned patient population for medical necessity, level of care and appropriateness of setting and services. Utilizes Milliman/Interqual Care Guidelines to track impact and variance.
• Discharge Planning: Collaborates with Social Worker proactively - arranges to meet facilities' target Discharge Time.  Initiates NaviHealth search for PAN refferrals.
• Proactively uses 3M report which assigns working MS/APR DRG in MIDAS daily, and queries, communicates and collaborates with nursing, physicians, and other healthcare professionals daily related to length of stay (LOS).
• Adheres to MCG process for documentation per training
• Documents delays of care and readmits appropriately and timely to develop potential trends and improved interventions.
• Payer Initiatives: Reconciles services available and rendered with patient benefit allowances to assure reimbursement and minimize financial losses for patient and hospital.
• Proactively refers cases to physician adviser for P2P, medical necessity review, and denail avoidance.
• Demonstrates and maintains current knowledge of regulatory agencies' relative to work process for compliance, i.e. IMM, Code 44  
• Timely communication with Admitting for status changes to ensure proper payer notification.
• Attends and actively participates in interdisciplinary patient care rounds on a daily basis and works with the health care team to collaboratively formulate appropriate and realistic discharge plans.
• Guest Relations/Communications: Demonstrates positive role modeling of customer relations (customers include patient, physicians, other health care team members, payers, etc.). Uses AIDET and KWKT appropriately.
• Quality/Outcomes Management: Identify and assist outcomes management process by referring and reporting variances in standards of care for identified patient populations.
• Change Management: Acts as a catalyst for change in the organization; responds to change with flexibility and adaptability to overcome organizational resistance and inertia; demonstrates the ability to focus and energize associates to work together for change; gains maximum support form others for new initiatives.
• Shaping the Organization: Devises systems and processes which improve the overall functioning of the organization; ensures that the organization’s systems, processes and people are integrated to achieve the mission in the most efficient and effective manner.
• Achieving Results: Demonstrates the confidence, drive and ability to face and overcome challenges and obstacles to achieve organizational goals.
• Enhancing Clinical Outcomes: Works to improve the healthcare process in general and devises and implements strategies specifically directed at improving clinical outcomes.
• Utilizes licensed evidenced-based tools (MCG / Interqual) to analyze and identify trends/patterns of performance through variance reporting to improve quality, satisfaction, and decrease cost variation.
• Age/cultural specific implications: Appropriately adapts assigned assessment, treatment and/or service methods to accommodate the unique physical, psychological, cultural, age-specific and other developmental needs of each member served.
• Core Values: Demonstrates adherence to the CORE values of Santa Rosa Health Care.
• Some weekend work and work after normal business hours may be required, as needed, to meet the needs of the facility and our patients.
• Performs other duties as directed.

Requirements:

• Graduate of an accredited school of Nursing required. BSN preferred.
• Proficient word processing skills in a Windows environment required.
• Ability to analyze and create reports and presentations via software applications.
• Familiarity with MIDAS and Meditech systems preferred. Bilingual (English/Spanish)preferred.
• A minimum of 5 years in clinical practice for population to be served is required.
• Case Management/Resource Management and discharge planning experience preferred. 
• Milliman (MCG) Guideline and Interqual criteria experience highly preferred.
• Currently licensed as RN in the State of Texas required
• CPR optional 
• Certification in Case Management preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time