Care Manager - Transition in Care (Remote)

Houston, TX, United States

At Houston Methodist, the Care Manager position is a licensed, experienced staff nurse responsible for partnering collaboratively with interprofessional healthcare team to provide professional nursing care and disease management to high risk patients and employees identified in the hospital and ambulatory setting. This position focuses efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness, decreasing preventable Emergency Department (ED) visits and readmissions while improving patient satisfaction. The Care Manager communicates with the physicians and the interprofessional health care team to facilitate and maintains compassionate, efficient quality care and achievement of desired treatment outcomes. This position demonstrates compassion and clinical competence when providing care, use of technology, and managing emergencies, and acting as a patient and family advocate in order to monitor and maintain patient rights. This position performs the duties and responsibilities of a Care Navigator as well as mentors new staff and helps drive change by identifying areas where performance improvement is needed and possibly contributing to program or hospital-wide initiatives at management's discretion (e.g., day-to-day workflow, education, process improvements, patient satisfaction).

PEOPLE ESSENTIAL FUNCTIONS

Serves as a clinical expert 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 care team to resolve problems that are identified during follow-up phone calls.

Mentors others in population health and other areas for skills development, coaching improvement, motivational interviewing techniques and other skills as needed. Assists with orientation for all new staff on specific programs.

Fosters teamwork by awareness of overall department activity, consistently offering assistance, and responding positively to requests for assistance. Collaborates balance within the work unit to foster a healthy work environment. Participates in huddles, meetings and team buildings.

Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Anticipates needs of other team members; proactively offers assistance. Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

Advocates on patient/family's behalf to identify and resolve clinical and ethical concerns, utilizing appropriate resources and assists in the identification and improvement to services by proactively identifying and resolving delays and obstacles for the patient.

Cross trains in other population health areas to be able to assist with departmental and staffing requirements as needed.

Identifies opportunities to improve patient satisfaction through collaboration with the interprofessional healthcare team, with focus on post discharge domain and collaborates with leadership to implement evidence-based patient engagement strategies. Contributes to improving score for patient satisfaction on program-based dashboard, through positive communication, proactive interventions, etc.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Assesses and monitors quality of community resources for the department to refer to and report back on patient satisfaction and engagement of the community partners to management. Contributes to meeting department goals and metrics.

Documents assessment and interventions efficiently and effectively.

Participates and contributes in department initiatives for quality and process/performance improvement. Presents and reports for the overall specific program, at CM staff meetings and department staff meetings on progress and new initiatives for their program.

FINANCE ESSENTIAL FUNCTIONS

Adheres to established productivity benchmarks; actively participates in decisions impacting operational and capital needs. Makes suggestions for cost saving measure for their program.

Contributes towards meeting department financial target on program-based dashboard through displaying self-motivation to independently manage time effectively, timely documentation of care, minimizing incidental overtime, decreasing length of stay, optimizing efficiency and other areas according to departmental specifications.

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 shared governance and leadership. Champion for patient devices and innovation projects.

Identifies department and cultural changes and presents areas for innovation, efficiency and improvement in patient care or unit operations using evidence-based practice literature. Offers innovative solutions through evidence-based practice/performance improvement projects and activities.

Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis.

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.

EDUCATION

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

WORK EXPERIENCE

Five (5) years clinical nursing experience which includes two (2) years care management experience, telehealth preferred

Chronic disease management experience preferred

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