Case Manager-RN/LVN/LMSW- Nexus Children's Hospital- Houston, TX


The Clinical Case Manager is responsible for assessing patient/family psychosocial needs, planning, implementing and evaluating care for patients across the healthcare episode. This position also assists in managing patient care to prevent fragmentation and duplication of services.

General Responsibilities:
• Maintains PHI and HIPAA for each patient by hospital policy and federal regulations.
• Promotes safety in the workplace and a safe patient environment at all times
• Practices “minimum information necessary” when performing case management and discharge functions
• Acts as a patient advocate for all facility patients
• Adheres to all company and professional ethical, legal and accreditation/regulatory standards
• Respects and promotes individual patient privacy and confidentiality
• Review, acknowledge, and schedule appointments/consults for in-house patients.
• Direct and guide assistant appointment scheduler as needed daily.
• Managing every patient’s insurance during an inpatient admission
• Submit prior-authorizations for ambulance transports per patient, per appointment.
• Demonstrates knowledge and support of the organization mission, vision, values, and strategic initiatives.
• Demonstrates an understanding of and upholds the organization’s Quality, Risk, and Continuum of Care program philosophy.
• Completes all initial assessments in initial case management treatment plan within two business days from the date of admission.
• Participate in Initial Multidisciplinary Team Conference and ongoing Team Conferences on each patient.
• Works in coordination with the multidisciplinary team to initiate a treatment plan, identify goals and interventions and establish discharge plans appropriate to medical, legal and social issues present by patient/family needs.
• Participates in weekly UM/UR meetings to review all DRG outlier cases for appropriateness of admission and discharge as well as the need for continued stay.
• Identify barriers and obtain appropriate physician intervention when necessary.
• Manage every patient’s length of stay along with the other Case Manager(s), physicians and multidisciplinary team to safely discharge the patient at the appropriate time.
• Maintains all case management documentation in the chart in a timely fashion, so all members of the team are aware of ongoing discharge planning progress or issues.
• Uses DRG and Case Management tools when appropriate to assist in the appropriate management of patient medical services and to facilitate discharge to the appropriate level of care in the most timely and cost-effective manner.
• Ensures timely consultations with specialists, specialized services or critical diagnostic tests are completed and results obtained to facilitate timely implementation of medical treatment.
• Collaborates with the treatment team and patient/family to prevent duplication or fragmentation of services.
• Conducts concurrent and retrospective reviews to identify and improve clinical, resource and system problems utilizing the continuous improvement process.
• Ensures and facilitates patient education as necessary to meet learning needs of specific patients and to ensure a safe discharge.
• Reports, coordinates, and maintains CPS logs of potential abuse and neglect for all patients by Federal, State and organization policies. Share this information with Quality Manager who maintains the CPS logs, and assists with necessary follow up as appropriate.
• Provides and maintains resource lists for patients and staff regarding financial and community resources for all age populations served.
• Provides a list of community resources to patient/families for discharge placement, DME, Home Health services as well as other community resources when appropriate and when specifically requested by patient/family members.
• Promotes interdepartmental communication and collaborative problem-solving about discharge planning needs and discharge plan.
• Actively coordinates and finalizes discharge plans to ensure smooth and timely discharge of patients with all appropriate services and equipment in a safe environment appropriate for patient/family needs.
• Appropriately documents the progress of discharge plans and services in multidisciplinary progress notes to ensure communication status is available to all team members.
• Follows all policies on documentation.
• Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system or community) which affect patient care, resource management or length of stay. Completes statistical and other reports as required promptly.
• Ensures utilization of medical resources for patients efficiently and effectively
• Maintains a safe environment
• Identified and function as a Meditech Super-user.
• Monitor, revise, review, manage and enforce case management and social work policies and procedures.
• Identified as the contact person between the corporate financial team and Nexus Children’s Facility.
• Participates in Quality Improvement, UM/UR Committee, and Risk Management as indicated
• Attends department and facility meetings as well as mandatory in-services’.
• Completes all Discharge documents for every patient to include: Patient Discharge Satisfaction Survey, Discharge Instructions and final discharge case management note in multidisciplinary progress notes by all established policies and procedures.
• Performs other duties as assigned.

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Job Requirements


• one (1) year experience in hospital case management, utilization management or discharge planning of complex medical/surgical/behavioral cases preferred, but willing to train the right candidate
• Proficient in use of InterQual, Milliman or other nationally recognized criteria
• Strong analytical and organizational skills
• Working knowledge and ability to apply professional standards of practice in the work environment.
• Knowledge of specific regulatory managed care and accreditation requirements
• Computer proficiency


• Must maintain current licensure in good standing during employment in Nursing or Social Work
• Certified in AHA Healthcare BLS/CPR
• Certified CPI/SAMA within ninety (90) days of hire
• Must obtain CEU’s by state requirements for licensure

Education Required

• Registered Nurse, Licensed MSW, or LVN with an active, unrestricted license in the State of Texas
• RN, BSN preferred
• CCM preferred or will obtain within three years of employment