Job Requirements

General Summary

Manages the daily operations of the department to include Care Management, Discharge and Transition Planning, and Utilization Management in accordance with regulatory requirements and the needs of the organization. Assumes responsibility for optimal clinical and financial outcomes across provider lines and systems in conjunction with all members of the healthcare team.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

Supervision

1. Regularly observes staff members in the performance of their duties to evaluate efficiency, skill, abilities, and attitudes toward coworkers and patients/customers; recommends appropriate corrective actions and performance evaluations. Maintains a consistent environment where employees are encouraged, reinforced, and supported in their desire to contribute fully.

2. Maintains ongoing communication with staff to maintain institutional and departmental goals and encourages staff participation and communication in decision-making.

3. Monitors reasons for reduction in patient satisfaction, re-admission and discharge appeals and reports trends to the Director.

4. Makes recommendations for personnel transfer, promotion, and specialized training to insure effective utilization of individual skills and employee development.

5. Serves as a resource for the staff providing expertise and guidance with regard to clinical activities.

6. Participates in departmental staff meetings to provide updates on regulatory changes, standard changes, problem identification and other appropriate matters.

7. Demonstrates ability and willingness to perform in-service education and development of staff and interdisciplinary teams. Maintains knowledge base to present accurate/current information.

8. Effectively participates in the development, revision, implementation, and communication of policies and procedures and standards for the staff in accordance with hospital and department policies and procedures.

Program Development & Maintenance / Performance Measurement

1. In collaboration with director, maintains an effective, organized care management program and interdepartmental programs that assure compliance with federal and state regulatory policies for hospital services of various regulatory agencies (PRO, Joint Commission, CMS and Department of Health and Mental Hygiene). Assist to establish program goals and objectives consistent with the hospital's mission and vision

2. Prepares and coordinates care management activities. Diplomatically negotiates with diverse groups of people in an exchange of information to provide regular reports.

3. Responsible for oversight of day-to-day operational procedures related to Care Manager data collection, patient through-put, and discharge planning. Assists to create, develop and trend reports of care management; collaborates with the Director to analyze and presents findings to leadership.

4. Collaborates with director in administrative planning and program development activities.

5. Monitors activities related to internal and external customers, e.g. nursing home, rehabilitation facilities, home health agencies, hospital outpatient services, etc., to achieve optimal customer relations while trying to assure reimbursement for hospital services.

6. Meets regularly with the Physician Advisor to exchange information, problem solve and maintain rapport.

7. Provides ongoing information to the Director regarding the programs, department, hospital wide activities, screening elements, communication from regulatory agencies and identified problems as appropriate

8. Collaborates with insurer groups to negotiate best options for patient care within insurer guidelines, including negotiating with the insurance company to consider out-of-network resource support or flexing of benefits where appropriate.

9. Exhibits responsiveness to all staff in the hospital and in other organizations. Functions as a representative of the Care Management Department with Administration and external agencies as requested by the Director.

10. Identifies opportunities for improvement in hospital systems, care provider practice patterns, patient/family/staff satisfaction, and resource utilization.

11. Other duties as assigned.

Work Experience

Education and Experience

1. BS in Nursing (Required); Master's Degree (Preferred)

2. Current RN license in State of MD

3. Minimum 5 years Case Management experience, which includes at least 2 years progressively responsible supervisory experience.