Care Manager I - Transition in Care (Remote - Must Live in Greater Houston)

Care Manager I

At Houston Methodist, the Care Manager I position is a licensed registered nurse (RN) who works collaboratively with the interprofessional healthcare team to provide professional nursing care and disease management to various population groups identified in the hospital and ambulatory setting and promotes the achievement of clinical and resource outcomes. This position focuses efforts on patient needs and outreach and coordination of care for a panel of patients promote wellness, decreasing preventable Emergency Department (ED) visits and readmissions while improving patient satisfaction. The Care Manager I position promotes and maintains compassionate, quality transitions of care through collaboration and appropriate communication with all interprofessional health care team members, patients and families. This position participates in department initiatives and shared governance, identifying and assisting with opportunities for performance improvement activities for the programs.

Houston Methodist Standard

Provide personalized care and service by consistently demonstrating our I CARE values:

• Integrity: We are honest and ethical in all we say and do.
• Compassion: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
• Accountability: We hold ourselves accountable for all our actions.
• Respect: We treat every individual as a person of worth, dignity, and value.
• Excellence: We strive to be the best at what we do and a model for others to emulate.

Practices the Caring and Serving Model

Delivers personalized service using HM Service Standards

Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

People Essential Functions

• Actively manages assigned panel of patients, using telephonic interaction as the mode of delivery that includes disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient. Facilitates access to care by assessing needs, offering clinical options, and referring to health care providers.
• Elicits, assesses and prioritizes patient information and recommends most appropriate level of care using evidenced-based protocols, working collaboratively and maintaining active communication with physicians, nurses, office staff and other members of the interprofessional healthcare team to resolve problems that are identified during follow-up phone calls.
• Coaches a population and family on self-management support including setting long and short term goals (including acute exacerbation management). Assists in setting SMART goals for self-management, teaching patients how to do self-management tasks and reports abnormal findings to their physician team.
• Serves as a clinical contact for hospital patients post discharge and in the ambulatory setting, working collaboratively and maintaining active communication with physicians, nurses, office staff and other members of the interprofessional healthcare team to resolve problems that are identified during follow-up phone calls.

Service Essential Functions

• Serves as a patient/employee advocate in preventing/resolving clinical or ethical issues and assists in the identification and improvement to services by proactively identifying and resolving delays and obstacles for the patient.
• Follows patients throughout the care continuum, including inpatient admissions, post hospitalization, and collaborating with inpatient care team management and community resources.

Quality/Safety Essential Functions

• Maintains detailed records to measure effectiveness of program throughout the process.
• Meets patient and patient family needs; takes responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
• Identifies opportunities to improve patient satisfaction with focus on discharge domain and collaborates with leadership to implement evidence-based patient engagement strategies.
• Participates in collaborative performance improvement activities.

Finance Essential Functions

• Adheres to established productivity benchmarks; participates in decisions impacting operational needs.
• Self-motivated to independently manage time effectively and prioritize daily tasks. Provides input into the unit resource utilization including capital and operational budget needs as appropriate.

Growth/Innovation Essential Functions

• Champions new care pathways or service line implementation to improve service to the community. Identifies trends for improvement opportunities or practice changes and supports initiatives. Researches the change and presents options to leadership.
• Identifies and presents areas for innovation, efficiency and improvement in patient care or department operations using evidence-based practice literature. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.
• Identifies own learning needs, consults with healthcare team experts and seeks continuing education opportunities to meet those needs. Seek out committees and events to participate in to develop networks within the HM system.

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.

Qualifications

Education

• Bachelor's degree or higher from an accredited school of nursing

Work Experience

• Five years hospital clinical nursing, case management and/or home health experience
• Experience in telehealth triage, emergency medicine, adult ambulatory care preferred

License/Certification

Licenses and Certifications - Required

• RN - Registered Nurse - Texas State Licensure -- Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) AND
• Health ServicesBLS - Basic Life Support or Instructor (AHA) AND
• Magnet-ANCC Recognized Certification (HM)

KSA/ Supplemental Data

Knowledge, Skills, and Abilities

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• 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
• 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
• Demonstrates respect for all individuals
• Strong assessment, organizational and problem solving skill as evidenced by capacity to prioritize multiple tasks and role components
• Able to work in a fast paced environment committed to providing immediate resolution to patient problems
• Demonstrates promptness to emails and phone calls from care team
• Proficient computer skills including data entry, retrieval and report generation; experience documenting in an Electronic Medical Record preferred
• Knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local and federal programs. Exhibits a workable knowledge of the teaching principles of health care information to adult and geriatric populations
• Ability to work independently while collaborating with other team members and exercise sound judgment in interactions with physicians, payors, and patients and their families

Supplemental Requirements

Work Attire

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

On-Call*

• On Call* Yes

Travel**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

Company Profile

Houston Methodist (HM) is one of the nation's leading health systems and academic medical centers. HM consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston metropolitan area. HM also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, HM employs over 25,000 employees. Houston Methodist is supported by a