The Registered Nurse Case Manager identifies, evaluates and provides management of services for patients with complex, catastrophic, long term illness or injury, mental/chemical health, and/or psychosocial issues. To promote quality, effective outcomes throughout the care continuum, the Case Manager will utilize disease management knowledge, along with evidence-based clinical care, to administer all facets of the case management process including assessment, planning, development of care plans, implementation of the plan of care, coordination and oversight of services, and evaluation of options and resources. The Case Manager acts as a member advocate through coordination and collaboration on care needs working with primary care physicians, specialists, members and their families, and community providers. The position responsibilities also include an understanding of the impact of social determinants of health and other psychosocial needs resulting in quality, cost-effective care.
Identification of members who will benefit from case management support
Utilization of evidence-based clinical practices to manage member needs, situations, strengths and resources to meet identified goals
Development of a plan of care focused on improving overall well-being, assuring use of evidence-based criteria throughout the continuum of care
Understanding and planning to assure services provided work within the boundaries of the member's plan eligibility
Engagement in ongoing timely professional collaboration and communication with the member, member's family and/or caregivers and healthcare providers according to member's healthcare needs to enhance positive outcomes
Research and refer members to community resources (i.e., food insecurities, child care, mental health/chemical health support)
Provide assistance to support the application of benefits assuring maximization of benefits to support identified needs
Perform ongoing essential case management activities of reassessment, problem identification, planning, implementation, coordination, monitoring, and evaluation of case managed members
Establish and maintain rapport with providers as well as ongoing education of providers concerning appropriate protocol
Facilitate negotiations for out of network care
Collaborate with all other departments as appropriate and required to facilitate the completion of tasks/goals
Perform telephonic communication with members in case management according to member needs and within Department of Defense contractual time frames
Facilitate patient wellness and autonomy through advocacy, communication, education, and identification of service resources
Identification of appropriate providers and facilities, assuring that available resources are being used in a timely and cost effective manner
Maintain quality documentation of collected data, actions taken, and results of actions taken in order to promote continuity of care within governmental and contractual requirements
Identify and present all cases of possible quality deviation, questionable admissions and out of network services to physician for review and recommendation
Analyze and present data related to medical services for cost containment
Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Adhere to NCQA and URAC standards
Graduate of an accredited Registered Nursing program, Bachelor's Degree required, Master's degree preferred.
Case Management Certification through an accredited organization required.
Program management experience, including management of multiple projects at one time.
Demonstrated organizational, time management, prioritization and team work skills.
Analytic ability to prepare and present status reports and document procedures.
Excellent communication skills, judgment, initiative, critical thinking and problem solving abilities.
Ability to handle and resolve complex issues.
Basic knowledge of computer systems; good typing skills.
Excellent customer service skills.
Excellent negotiation skills.
Minimum five years of diverse clinical experience as a Registered Nurse.
Minimum three years in the role of case/utilization manager.
Five years of experience working with evidence based guidelines.
Three years of experience independently managing patients providing clinical guidance.
Three years of experience working with care providers to develop and manage plans of care.
Three years of program/project management experience focused on patient care.
Current/Active Texas RN Licensure.
Additional RN certification in Chronic Care or Specialty Care preferred.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.