Job Description

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Position Summary

Serves as the central resource for the Executive Team concerning strategies which are efficient, effective, timely, patient-centered, and support appropriate financial reimbursement. Assumes 24-hour accountability for planning and direction of departments that provide: Access, Utilization Review, Denials and Appeals, Care Coordination, Discharge Planning, Clinical Social Work, Recovery and Disease Management, and Contracting. Collaborates with all disciplines, departments, payers, system partners, vendors, and community agencies to optimize clinical outcomes within best practice, ethical, legal, and regulatory parameters.

Essential Functions and Responsibilities Includes the Following:

• Understands and adheres to the Performance Standards, Policies and Behaviors
• Oversee the day-to-day operations of the Care Management Department including hiring, educating, disciplining, budget maintenance.
• Responsible for the planning, organizing, directing and supervising of designated care managers within the nursing division.
• Assures the delivery of quality department/clinical services in accordance with established hospital and regulatory/accreditation agency standards.
• Responsible and accountable for the overall operations of their assigned division. Overall operations of the department include development of department goals and objectives that are consistent with the hospital mission, the management of personnel, preparing/monitoring of and accountability for the department budgets.
• Assists Nurse Care Manager and Social Work Manager in budget development and control, standard setting, policy development, goal settings, and evaluation of patient care.
• Provides strategy formulation, coordination of resources, and establishment, implementation and evaluation of financial and business goals for assigned product lines.
• Responsible for the Care Management Dashboard,
• Works collaboratively with all levels of the hospital interdisciplinary team and promotes the team concept within their division and hospital wide.
• Demonstrates positive customer service, fosters positive employee relations and assures that staff adhere to the Customer Service Behavioral Standards.
• As required, participates in the Performance Improvement Program as defined by the organization.
• Is responsible for participation in committees, task forces and projects as appropriate.
• Attends Management/Leadership meetings as scheduled/required.
• Guides Nurse Care Manager and Social Work Manager as they develop organizational plans for their individual units and services
• Counsel and supervise the work of Nurse Care Manager and Social Work Manager.
• Provides individual guidance and leadership as needed for Nurse Care Manager and Social Work Manager.
• Ensure departmental/organizational goals are realized for: length of stay reduction, readmission reduction, denial reduction, improve discharge satisfaction, appropriateness of transitional planning
• Ensure departmental policies are compliant with regulatory requirements.
• Member of various hospital committees.
• Oversee Utilization Review Committee Meeting/agenda
• Maintains effective and professional relationships with all members of the healthcare team, administration and aftercare providers
• Performs all other related duties as assigned

Education & Experience Requirements

IF RN: RN with BSN or MSN required or BSN and a Master’s degree in clinical of health care administration, CMAC (Certified as a Case Management Administrator) or CCM (Certified Case Manager) certification preferred

IF SW: Master’s degree in social work, Licensed Social Worker (LMSW or LCSW), CMAC (Certified as a Case Management Administrator) or CCM (Certified Case Manager) certification preferred

Minimum Knowledge and Education :

1. Computer skills

2. Critical thinking

3. DRGs, Medicare Regulations, Medical Necessity Criteria

4. Patient Bill of Rights, HIPAA

Minimum Work Experience :

1. 1-year acute hospital experience, AND

2. 1 year experience in non-hospital-based health care (home care, insurance, outpatient, etc.)

3. Previous experience managing staff or successful project implementation

Specific Knowledge, Skills, Abilities :

1. Human resource management

2. Program evaluation and outcomes management

3. Market assessment and strategic planning

4. Leadership for change/change management

5. Assessment of clinical systems

6. Identification of at-risk populations

7. Development of strategies to manage at-risk populations

8. Collaborative, energetic, proactive

9. Technical writing for reports, letters, proposals, etc.

Core Competencies

Demonstrates ability to establish two-way communication by clearly defining expectations, communicating utilizing a variety of methods, actively listening to ideas and concerns and responding in an appropriate manner.

Demonstrates ability to delegate responsibilities appropriately.

Demonstrates the ability to retain composure under stress.

Physical/Mental Demands/Requirements & Work Environment

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS database can also be found on the hospital switchboard, saved on a disc
• Must be physically able to walk, stand and or sit for extended periods of time with the ability to carry necessary equipment (i.e.: iPad or laptop) on rounds. Must be able to perform difficult manipulative, arm-hand steadiness and hand eye coordination skills. Must be able to meet all regulatory requirements.
• Demonstrates ability to follow written and oral instructions required for the position.
• Demonstrates ability to analyze multidimensional problems into component parts and sort out tasks in priority order to solve the problem.
• Must be able to see object closely and far away, hear normal sounds with some background noise. Communicates effectively verbally and in writing.

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