Description
Summary:
The Care Manager (CM) II works in collaboration with the patient/family, physicians and multidisciplinary team members to ensure patient progression through the continuum of care and to develop a plan of care for each assigned patient from admission through discharge. The CM is responsible for identifying, initiating and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, and length of stay management. Support and expertise are provided through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Care Coordination and Discharge Planning are both responsibilities of this role. The CM assesses and responds to patient/family needs by coordinating efforts of other team members and identifies and resolves barriers that hinder effective patient care. The CM adheres to departmental and organizational goals, objectives, standards of performance, policies and procedures, and continually assures regulatory compliance.
CHRISTUS Santa Rosa Hospital – San Marcos, which originated in 1923 as Hays County Soldiers, Sailors and Marines Memorial Hospital, opened at its current Wonder World Drive location in 1983. Our staff of more than 700 Associates works with more than 300 active and consulting physicians to provide quality services to patients and their families. For more than 20 consecutive years, we have been named The Best Hospital in Hays County in the annual “Best of Hays” publication released by the San Marcos Daily Record. In addition to interventional cardiac services, CHRISTUS Santa Rosa Hospital – San Marcos is a Certified Chest Pain Center and an accredited Primary Stroke Center. We lead the region in da Vinci robotic-assisted surgery and offers a variety of specialty care services including medical imaging, rehabilitation, hospice, women’s services and more.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Coordinates the integration of case management functions into the patient care and discharge planning processes in collaboration with other hospital departments, external service organizations, agencies, and healthcare facilities.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as resource, provides support, and advocates on behalf of the patient related to treatment decisions and end of life issues.
• Closely monitor patient length of stay in regard to the geometric mean length of stay and communicate/collaborate with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Implements and monitors the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Proactively identifies and resolves delays and obstacles to discharge.
• Uses advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Interviews patients/families to obtain information about social, emotional, and financial factors which impact health status to develop comprehensive discharge planning assessment and care plan.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post-acute level of care needs and options including:
• Acute Rehabilitation Placement
• Nursing Home or Skilled Nursing placement
• Psychiatric or Substance Abuse placement
• New Dialysis
• Child/Adult/Domestic Abuse
• Home Health/Hospice Referrals
• Legal issues (adoptions, guardianship)
• Assistance with Advance Directives
• Community Resource needs
• Financial Issues/Funding options
• DME Referrals and Coordination
• Social Determinants of Health
• Initiates discharge planning at the time of admission and makes post-hospital service referrals based upon information gathered during assessment and interactions with physicians, multidisciplinary care team, and payors as indicated.
• Acts as patient advocate by negotiating for, and coordinating, resources with payors, agencies, and vendors.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population.
• Assesses the patient’s formal and informal support system as well as available benefits and/or community resources.
• Meets directly with patient/family to assess needs and develop and individualized care plan in collaboration with the physician.
• Ensures and maintains plan consensus from patient/family, physician and payor.
• Provides education, information, direction, and support related to patient’s goals of care.
• Acts as patient advocate to develop treatment plan and coordinate patient care and to transition patient to the appropriate next level of care.
• Demonstrates and promotes respect for the dignity and rights of every patient while adhering to the safety standards and practices of the organization and the nursing profession.
• Collaborates with the physician and other health care professionals to promote appropriate use of medical center resources.
• Provides information and support to patients and families, helping them access needed resources within the medical center and community.
• Actively participates in clinical performance improvement activities involving length of stay, resource utilization, avoidable days, cost per case, and readmissions.
• Measures effectiveness of interventions through direct communication with post-acute care providers, patients, and caregivers.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
• Actively participates in Multidisciplinary/Patient Care Progression Rounds.
• Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
• Documents in the medical record per regulatory and department guidelines.
• May be asked to assist with special projects.
• May serve a preceptor or orienter to new associates.
• Assumes responsibility for professional growth and development.
• Must have excellent verbal and written communication and ability to interact with diverse populations.
• Must have critical and analytical thinking skills.
• Must have demonstrated clinical competency.
• Must have the ability to Multitask and to function in a stressful and fast paced environment.
• Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Must have understanding of pre-acute and post-acute levels of care and community resources.
• Must have ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families.
• Must be understanding of internal and external resources and knowledge of available community resources.
• Must have the ability to move around the hospital to all areas for the majority of the workday while in office the rest of the day; general office and hospital environment.

Job Requirements:

EDUCATION/SKILLS

• Graduate of an accredited school of nursing (BSN preferred) or Masters Degree in Social Work (MSW) required or demonstrated success in CHRISTUS Care Manager I Position for at least 5 years on top of the required experience in lieu of education required.

EXPERIENCE

• Two or more years clinical experience with one year in the acute care setting preferred.

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Coordinates the integration of case management functions into the patient care and discharge planning processes in collaboration with other hospital departments, external service organizations, agencies, and healthcare facilities.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as resource, provides support, and advocates on behalf of the patient related to treatment decisions and end of life issues.
• Closely monitor patient length of stay in regard to the geometric mean length of stay and communicate/collaborate with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Implements and monitors the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Proactively identifies and resolves delays and obstacles to discharge.
• Uses advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Interviews patients/families to obtain information about social, emotional, and financial factors which impact health status to develop comprehensive discharge planning assessment and care plan.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post-acute level of care needs and options including:
• Acute Rehabilitation Placement
• Nursing Home or Skilled Nursing placement
• Psychiatric or Substance Abuse placement
• New Dialysis
• Child/Adult/Domestic Abuse
• Home Health/Hospice Referrals
• Legal issues (adoptions, guardianship)
• Assistance with Advance Directives
• Community Resource needs
• Financial Issues/Funding options
• DME Referrals and Coordination
• Social Determinants of Health
• Initiates discharge planning at the time of admission and makes post-hospital service referrals based upon information gathered during assessment and interactions with physicians, multidisciplinary care team, and payors as indicated.
• Acts as patient advocate by negotiating for, and coordinating, resources with payors, agencies, and vendors.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population.
• Assesses the patient’s formal and informal support system as well as available benefits and/or community resources.
• Meets directly with patient/family to assess needs and develop and individualized care plan in collaboration with the physician.
• Ensures and maintains plan consensus from patient/family, physician and payor.
• Provides education, information, direction, and support related to patient’s goals of care.
• Acts as patient advocate to develop treatment plan and coordinate patient care and to transition patient to the appropriate next level of care.
• Demonstrates and promotes respect for the dignity and rights of every patient while adhering to the safety standards and practices of the organization and the nursing profession.
• Collaborates with the physician and other health care professionals to promote appropriate use of medical center resources.
• Provides information and support to patients and families, helping them access needed resources within the medical center and community.
• Actively participates in clinical performance improvement activities involving length of stay, resource utilization, avoidable days, cost per case, and readmissions.
• Measures effectiveness of interventions through direct communication with post-acute care providers, patients, and caregivers.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
• Actively participates in Multidisciplinary/Patient Care Progression Rounds.
• Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
• Documents in the medical record per regulatory and department guidelines.
• May be asked to assist with special projects.
• May serve a preceptor or orienter to new associates.
• Assumes responsibility for professional growth and development.
• Must have excellent verbal and written communication and ability to interact with diverse populations.
• Must have critical and analytical thinking skills.
• Must have demonstrated clinical competency.
• Must have the ability to Multitask and to function in a stressful and fast paced environment.
• Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Must have understanding of pre-acute and post-acute levels of care and community resources.
• Must have ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families.
• Must be understanding of internal and external resources and knowledge of available community resources.
• Must have the ability to move around the hospital to all areas for the majority of the workday while in office the rest of the day; general office and hospital environment