DIRECTOR CASE MANAGEMENT
Detroit, MI
Full Time
Mid Level
JOB DESCRIPTION
Industry: Healthcare / Health Services - Nursing / LPNs / LVNs
Job Category: Medical / Health - Nurse Leadership
Hospital:
Qualifications – External
POSITION SPECIFIC RESPONSIBILITIES:
Department Operations
· Maintains an adequate number and skill mix over seven days a week to serve the patient population and meet the goals of the department
· Implements and supports with business case staffing requests utilizing the Tenet Case Management staffing recommendations and hospital budgetary guidelines
· Holds regular departmental meetings with staff to provide updates and provides for ongoing education
· Completes initial and annual competency and evaluation review on all case management staff
· Follows the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
· Develops action plan for case managers that fail to meet the IRR acceptable “match” rate to ensure improvement in the accurate application of InterQual criteria
Utilization Management
§ Implements and monitors processes to ensure medical necessity review processes are in place for patients to be in the appropriate status and level of care per Tenet policy.
§ Oversees submission of cases to Physician Advisor review to ensure timely referral, follow up and documentation.
§ Implements and monitors utilization review process in place to communicate appropriate clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services.
· Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
· Implements and monitors physician “peer to peer” review process with payers to resolve denials or downgrades concurrently.
Transition Management
· Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
· Ensures case management staff use electronic referral request process for patient placements
· Monitors to ensure that patient choice is documented per CMS regulations and Tenet policy
Care Coordination
· Works with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
· Participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
· Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient choice and available resources
· Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
· Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
· Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
Education
· Provides education to physicians regarding medical necessity, complete and accurate documentation, and compliance with related regulatory requirements
· Prepares and provides data to physicians and the hospital on utilization of resources
· Provides education to case management staff, physicians and the healthcare team.
Compliance
· Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
· Ensures that the department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
· Operates within the RN scope of practice as defined by state licensing regulations
Minimum Qualifications
1. Graduate from an accredited school of Nursing. Bachelor’s degree in Nursing or other health-related field, or the equivalent combination of education and/or related experience. Master’s degree in Nursing, Business Administration or Hospital Administration preferred.
2. Licensed to practice as a Registered Nurse in the State of Michigan;
3. Three to five years of acute hospital case management leadership experience. Five years acute hospital case management experience preferred. McKesson InterQual® experience preferred. Business planning experience preferred.
4. Accredited Case Manager (ACM) preferred.
Skills Required
1. Analytical ability to serve in an advisory/consultative role in determining and/or developing strategies, policies, processes, protocols and methods, frequently in the absence of guidelines or technical assistance, and to evaluate and direct complex systems that foster innovative approaches to procedures/processes.
2. Fiscal skills to monitor and control costs and revenue.
3. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
4. Strong communication and interpersonal skills for frequent contacts with internal customers as well as stakeholders external to the DMC to persuade or negotiate on a wide range of subjects in situations which may be controversial, sensitive and/or lead to confrontation. A mastery of a variety of communication modalities is required to include leading meetings, making formal presentations, and writing complex documents and managing complex relationships over time.
5. Teaching abilities to conduct educational programs for staff.
6. Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful yet timely manner.
7. Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability, comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
8. Technical knowledge of community resources, regulatory requirements, reimbursements and utilization management procedures in order to function as a resource for staff.
Security Clearance Required: No
Visa Candidate Considered: No
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