319 Best medical review nurse Jobs in Houston, Texas (May 2026) - page 4

Market Director of Case Management

22 days ago

Houston

Job Description POSITION SUMMARY: The Market Director of Case Management provides operational and clinical leadership for all case management, utilization review, and discharge planning functions across assigned market facilities of Nexus Health Systems. This role ensures effective care coordination, regulatory compliance, patient throughput, and optimal length of stay while aligning market-level execution with systemwide case management strategy for the market specialty hospitals with a focus on neurodevelopmental disorders and co-occurring complex behavioral and medical conditions. The Market Director partners closely with hospital executives, medical staff, nursing leadership, and corporate teams to support quality outcomes, patient experience, and financial performance. JOB-SPECIFIC RESPONSIBILITIES: • Service o Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems o Upholds the Standards of conduct and corporate compliance o Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations. o Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job. o Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI) o Collaborates effectively with colleagues and other departments to ensure seamless service delivery. o Directs the daily operations of the Case Management Department, ensuring efficient and effective service delivery. o Facilitates coordination among healthcare teams to develop and implement comprehensive care plans. o Establishes and nurtures relationships with insurance providers, healthcare networks, and community resources to optimize patient care and service delivery. o Collaborates with the treatment team and patient/family to prevent duplication or fragmentation of services. • Clinical Excellence o Lead market-wide case management operations (screening, assessment, care planning, UR, discharge/transition planning) and standardize workflows across facilities to meet CMS Conditions of Participation for Discharge Planning (§482.43) and Utilization Review (§482.30). o Establish and oversee a Utilization Review Committee that meets regulatory requirements and integrates physician advisors for complex determinations. o Implement American Case Management Association (ACMA)/ Case Management Society of America (CMSA) standards of practice for care management and transitions of care. o Apply InterQual® criteria for admission status, continued stay reviews, discharge readiness, and level-of-care decisions. o Collaborate with physician advisors to ensure consistent medical necessity determinations and documentation quality. o Embed Neurodevelopmental Disabilities (NDD)-informed care practices (sensory accommodations, communication supports, caregiver engagement) into case management workflows. o Use Agency for Healthcare Research and Quality (AHRQ) care coordination frameworks to align multidisciplinary goals and transitions. o Provides guidance and support to case managers, ensuring adherence to best practices and clinical guidelines. o Monitors patient progress, consulting with healthcare teams to adjust treatment plans as necessary for optimal outcomes. o Ensures comprehensive and accurate documentation of patient care, facilitating continuity and quality of care. o Identifies areas for clinical improvement and implements strategies to enhance patient care and service delivery. o Supervises and assists in obtaining physician documentation in the medical record to support the current treatment level, medical necessity of continued stay, and documentation of all current diagnoses being actively treated. o Collaborates with all interdisciplinary department directors to coordinate the multidisciplinary treatment plan, identify goals and interventions, and establish discharge plans appropriate to medical, legal, and social issues. o Leads the Initial Multidisciplinary Team Conference and co-chairs ongoing Team Conferences. o Conducts concurrent and retrospective reviews to identify and improve clinical, resource, and system problems utilizing the continuous improvement process. o Recognizes the importance of documentation improvement and its relation to patient care and fiscal reimbursement. o Supervises case managers via case reviews to ensure coordination and finalization of discharge plans, ensuring services and equipment for safe discharge. o Supervises department to ensure safety in the workplace and a safe patient environment at all times. o Reports, coordinates with, and maintains APS/CPS documentation of potential abuse and neglect in accordance with Federal, State, and organization policies. o Provides ongoing supervision of individual case management cases to ensure appropriate and timely use of medical resources and discharge planning implementation. o Provides training and oversight in using ELOS and InterQual as tools to assist in the appropriate management of patient medical services and facilitate discharge to the appropriate care level in the most timely and cost-effective manner. • Patient Experience and Advocacy o Ensure person-centered discharge planning that reflects patient goals and includes caregivers as active partners. o Champion patient advocacy and access principles aligned with Utilization Review Accreditation Commission (URAC) Case Management Accreditation standards. o Promote sensory-friendly environments and communication supports for neurodiverse patients. o Advocates for patients and families, ensuring their needs and preferences are central to care planning and delivery. o Leads the development and implementation of discharge plans, ensuring patients transition smoothly from hospital to home or other care settings. o Provides guidance on accessing community resources, financial assistance, and support services to meet patients' needs. o Oversees the development and delivery of educational materials and sessions to empower patients and families in managing health conditions. o Consults, assists, and intervenes regarding the end-of-life care for patients. o Advocates for the patient while balancing the responsibility of stewardship and the judicial management of resources. o Provides and maintains resource lists for case managers to share with patients and staff regarding financial and community resources for all age populations served. • Quality Assurance and Compliance o Ensures all activities adhere to healthcare regulations and organizational policies. o Participates in quality improvement initiatives to enhance service delivery. o Promotes a culture of patient safety which results in the identification and reduction of unsafe practices. o Conduct audits for UR and discharge planning compliance; monitor timeliness, completeness, and appeal outcomes. o Support accreditation efforts (URAC, ACMA) and embed performance improvement initiatives. o Leads initiatives to enhance case management practices, fostering a culture of continuous quality improvement. o Prepares for and supports accreditation processes, ensuring all standards and requirements are met. o Ensures compliance with federal, state, and local regulations, as well as organizational policies related to case management. • Professional Growth and Continuing Education o Completes annual education requirements. o Maintains competency, as evidenced by completion of competency validation requirements. o Maintains competency and knowledge of current standards of practice, trends, and developments. o Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices. o Oversees the recruitment, training, and professional development of case management staff, ensuring they possess the necessary skills and knowledge. o Provides mentorship and coaching to case managers, fostering a supportive environment for professional growth. o Develops and implements educational programs to enhance staff competencies and keep them abreast of industry trends and best practices. o Encourages and supports staff in obtaining relevant certifications to enhance professional credentials. o Develop competency pathways and leadership development programs for case management teams. o Encourage staff certification (e.g., CCM, ACM-RN/ACM-SW, CPHQ) and provide annual training on InterQual® criteria, CMS CoPs, and NDD-informed care. • Finance: o Promotes stewardship of hospital resources while ensuring quality patient care. o Optimize LOS using InterQual® Goal Length of Stay benchmarks; reduce avoidable days and prevent denials through proactive medical necessity reviews. o Lead payer engagement and appeals management in collaboration with physician advisors. o Monitor throughput, case mix, and financial performance metrics. o Oversees the allocation of departmental resources, ensuring they are utilized effectively to meet patient needs and organizational goals. o Develops and manages the case management department's budget, ensuring financial resources are allocated effectively. o Identifies opportunities for cost savings without compromising patient care, implementing strategies to reduce expenses. o Prepares financial reports related to case management activities, providing insights into resource utilization and financial performance. o Participates in negotiations with insurance providers and other stakeholders to secure favorable terms for case management services. o Ensures provision of case management, utilization management, and discharge planning equally to all patients regardless of payor source. o Supervises and promotes appropriate documentation to support medical necessity and resource use that impacts fiscal reimbursement. o Provides oversight in the use of tools (e.g., ELOS and InterQual) to facilitate cost-effective discharge planning. • Performs other duties as assigned. POSITION QUALIFICATIONS: EDUCATION: • Bachelor’s degree in Nursing (BSN) or Social Work required, • Master’s in Nursing (MSN), or Master Social Work (MSW) require EXPERIENCE: • Minimum 7 years progressive leadership in hospital case management, including UR and discharge planning; multi-site experience preferred., • Experience with neurodevelopmental/behavioral health populations and complex medical conditions strongly desired., • Strong analytical and organizational skills, • Proficient knowledge of DNV/Joint Commission accreditation requirements, CMS and state regulatory requirements and care management and utilization management., • Proficient in knowledge and ability to apply professional standards of practice in Case Management, RN, LBSW, and LMSW practice. SKILLS: • Expert knowledge of CMS CoPs, Joint Commission standards, and URAC principles., • Proficiency in InterQual® criteria for medical necessity and level-of-care determinations., • Strong communication, care coordination, and advocacy skills; familiarity with NDD-informed practices., • Ability to apply critical thinking and clinical judgment in diverse and complex patient scenarios., • Communicates clearly with patients, families, and healthcare teams, providing updates and support., • Effective communication skills with both patients and families, especially in stressful or crisis situations., • Compassionate, patient-centered approach to care, with the ability to manage challenging patient behaviors and emotional needs., • Proficient in managing patients with behavioral health needs., • Strong organizational skills with the ability to manage multiple tasks effectively in a dynamic environment., • Prioritizes tasks efficiently in fast-paced environments and manages multiple patient needs., • Works effectively with multidisciplinary teams, ensuring coordinated care., • Adheres to safety protocols, infection control standards, and best practices., • Competent in using electronic health record (EHR) systems and medical equipment for patient care documentation., • Background in business planning, and targeted outcomes., • Working knowledge of managed care, inpatient, outpatient, and the home health continuum, as well as utilization, • management and case management., • Working knowledge of the concepts associated with Performance Improvement., • Demonstrated effective working relationship with physicians. LICENSURE/CERTIFICATION: • Current and valid license to practice as a Registered Nurse in the state of Texas or Current and valid Texas license as a Licensed Bachelor of Social Worker (LBSW) or Licensed Master of Social Worker (LMSW) required., • Case Management Certification is required from accredited professional organization (i.e. ACM, CCM, CMGT, FAACM). If not currently held at the time of appointment, it must be obtained within two years., • BLS (Basic Life Support) from American Heart Association//American Red Cross required, must be valid for a minimum of 6 months from date of hire., • De-escalation training within 30 days after hire., • Must maintain current certification in good standing during employment with this facility.

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