Under the direction of the Medical Management Director, the Case Manager/Nurse Navigator Level I serves in an expanded nursing role to identify, evaluate, and implement all options and services with the goals of optimizing the member's health status. Members may have complex, catastrophic, long term illness or injury, Behavioral Health conditions, Pediatric conditions, high risk pregnancy, targeted chronic conditions or be in need of transition of care services. The Case Manage/Nurse Navigator promotes quality, cost-effective outcomes throughout the care continuum, utilizing the nursing process and critical thinking skills to administer all facets of the case management process in the implementation of the nursing plan of care, coordination and oversight of services, and evaluation of service options.
The Case Manager/Nurse Navigator will identify and enroll patients with complex and chronic health conditions and/or refer to other services/programs per policies. The Case Manager will support transitions of care as assigned and/or chronic condition support or health and wellness programs for the assigned population.
Depending upon the primary role, the Case Manager maintains an average of 50-75 complex active cases per month or an average of 75-100 total active cases per month which include a combination of complex and general case management cases. Nurse Navigators for Population Health may maintain larger caseloads of 150-200 patients.
The Case Manager/Nurse Navigator acts as a member advocate, facilitates communication and coordinates care with physicians, the provider's clinic, hospital facilities, family, caregivers and other healthcare providers, and implements creative solutions to meet members' health care needs without compromising quality of outcomes. The position responsibilities also include supporting health risk reduction through behavioral change, patient education and reducing preventable readmission rates by supporting discharge planning to the next level of care and educating and stabilizing the member in their healthcare setting.
Perform ongoing essential Case Management (CM) activities of assessment, barrier and strengths identification, planning, implementation, coordination, monitoring, and evaluation of case managed members.
Design an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, their support system, primary care provider, and other members of the health care team to ensure coordination of services.
Patient support activities performed in this role include but are not limited to: Complex Case Management, High Risk Disease Management, Transition of Care management, Health Promotion, Care Coordiantion and Health Coaching
Implement, evaluate and revise case management treatment plans according to eligibility criteria, contractual guidelines and member's physical and psychological needs throughout the continuum of care.
Note: Some Case Managers may be assigned Transitions of Care patients and will also be responsible to ensure a safe and effective transition from the inpatient setting to the community (e.g. home, rehabilitation, residential treatment services or SNF)
Note: Some Case Managers may be assigned to ACO Nurse Navigation, Maternity, AA/PCA, Behavioral Health or Pediatric patients and will also be responsible to support the specific clinical needs and regulatory requirements for these special health populations.
Note: Some Case Managers may be assigned patients with chronic conditions and will also be responsible to close their assigned patients gaps in care, comply with HEDIS standards and provide motivational interviewing support and education Engage in ongoing timely professional collaboration and communication with the CHRISTUS Health associate, associate's family and/or caregivers and healthcare providers according to member's healthcare needs to enhance positive outcomes
Coordinate plan of care for high risk/high cost patients or those receiving care through out of network providers, within required governmental and contractual guidelines.
Promotes patient knowledge and behavior change support to members with ongoing chronic conditions or special healthcare needs within the first 7-10 days of initial contact.
Establish and maintain rapport with providers as well as ongoing education of providers concerning appropriate protocols, evidence based guidelines and patient status. Support integrated care for appropriate populations.
Collaborate with other departments as appropriate and required to facilitate the completion of case and health management tasks and goals.
Contact the provider of services for time urgent services (e.g. oxygen, IV therapy, walker post knee surgery, routine DME, Home Health, etc.)
Facilitate members' autonomy through obtaining input into their plan of care, advocacy, communication, education, and identification of service resources.
Support cost effective care by assuring in-network resources are being used in a timely manner whenever possible. Collaborate with provider relations for out of network contracting as needed.
Maintain documentation for all health management and case management activities to meet all regulatory and contractual requirements.
Maintain a full patient caseload that includes ongoing enrollment of new patients and closure of cases when the patient has met their goals.
Demonstrate organizational, time management, prioritization and team work skills.
Work autonomously and be directly accountable for results.
Build positive professional relationships to support case management activities
Function effectively in a fluid, dynamic, and changing environment.
Able to positively influence behavior and outcomes.
Protects confidentiality of data and intellectual property; assures compliance with national health information guidelines.
Maintains, obtains all professional CEU's in compliance with State and Regulatory requirements.
Adhere to URAC and NCQA standards pertaining to Disease Management and Case Management.
Ability to work occasional long or irregular hours
Ability to work a flexible work schedule
Associate or Bachelor Degree in Nursing required; Bachelor Degree preferred
Competent in Microsoft software (e.g. Word and Excel)
General computer knowledge and capability to use computers required.
Excellent telephonic customer service skills
Knowledge of motivational interviewing and supporting behavioral change
Excellent communication skills, (written and verbal) judgment, initiative, critical thinking and problem-solving abilities
Minimum of 1-3 years of case or disease management experience, in a managed care environment or health plan preferred
Minimum of 3 years of general or specialty nursing experience
Ability to work in a variety of settings with culturally-diverse families and communities with the ability to be culturally sensitive and appropriate
Knowledge of managed care principles, HMO and Risk Contracting arrangements.
Knowledge of case management standards of practice
Licenses, Registrations, or Certifications
Licensed registered nurse (current and unrestricted) in the State of Texas
Certification in Case Management or Chronic Care Professional required. Certification in Case Management must be achieved within two years of hire.
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.