Case Manager Care Coordinator - Full-Time


The Case Manager is responsible for directing and coordinating the delivery of health care services and collaborating with the multidisciplinary team to create a safe discharge plan. The Case Manager facilitates communication and coordination between the health care team members and involves both the patient and family in the decision-making process.  Activities include encouraging appropriate use of health care resources, striving to improve quality of care, maintain cost-effectiveness for each patient’s individualized plan of care and to safely transition to the next most appropriate site of care. Completes case management intake assessments within 72 business hours of admission as required to obtain social functioning information and identify resources available for coordination of care and discharge planning.

  • · Assists in providing information to family regarding possible community resources to be utilized in supporting
  • patients continued needs.
  • · Advocate for the patient during hospitalization, from admission to post-discharge.
  • · Collaborates with the physicians and other members of the multidisciplinary team to facilitate care.
  • · Monitors the patient’s progress, intervening as necessary and appropriately to ensure that the plan of care and
  • services provided are patient focused, high quality, efficient, and cost effective throughout the continuum.
  • · Facilitates necessary referrals for imaging, specialty appointments and procedures for comprehensive care while
  • inpatient.
  • · Facilitates transfer to other facilities when appropriate and necessary.
  • · Completes and submits prior authorizations.
  • · Schedules transportation.
  • · Communicates with patient/family and multidisciplinary team throughout the discharge planning process,
  • including information obtained from initial and ongoing case management assessments, planning,
  • implementation, interdisciplinary collaboration, progress, and family education/training.
  • · Coordinates and facilitates Family Care Conferences.
  • · Proactively identifies barriers to discharge and works on resolution.
  • · Collaborates/communicates with external case managers including CPS to identify and utilize available resources
  • for post discharge needs.
  • · Coordinates discharge referrals – DME, home health, hospice, outpatient follow up appointments, and other
  • recommendations by the treatment team.
  • · Documents in the medical record per department standards.
  • · Actively participates in clinical performance and process improvement activities.
  • · Acts as preceptor/mentor to new hires.
  • · Promotes individual professional growth and development by meeting requirements for mandatory/continuing education. ·
  • Supports department-based goals which contribute to the success of the organization.
  •  Exhibits a positive professional demeanor to patients, family/support persons, offering constructive communication, cooperation, and assistance to ensure a satisfactory patient stay of treatment.
  •  Respectful of other points of view and builds positive relationships with co-workers. ·
  • Performs other duties as assigned.
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Job Requirements


  • Three (3) years of experience in hospital-based nursing or social work.
  • · Prefer experience in pediatric, complex medical, rehabilitation, and/or behavioral case management.
  • · Current working knowledge of discharge planning, utilization management, case management, performance
  • improvement, disease or population management and managed care reimbursement.
  • · Excellent interpersonal communication skills.
  • · Demonstrated leadership skills.
  • · Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role
  • components.
  • · Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients
  • and their families.
  • · Effective oral and written communication skills
  • · Proficient in computer skills of the entire Microsoft 365 (Excel, Outlook, Sharepoint, Word and Teams).
  • · Demonstrates commitment to the Partners-in-Caring process.

Education Required

  • Graduate of an accredited school of professional nursing required; Bachelors of Nursing preferred, or graduate of an accredited masters of social work program.

Additional Information


  • Current and valid license to practice as a Licensed Vocational Nurse or Registered Nurse in the state of Texas; or
  •  Current and valid license as a Licensed Master Social Worker (LMSW) in the state of Texas
  • Current BLS certification