JOB SUMMARY

Responsible for the management and overall activities and functions of the Case Management and Utilization Review department. Department services include Care Coordination, Discharge Planning, Utilization Review, Denials Management and Case Management. Provides support/replacement when the Care Coordinator, Utilization Review Nurse or the Discharge planner are not available or are overtaxed and require assistance. Produces and manages agreed upon metrics and reports for distribution to other stakeholders per policy and procedure. Provides operational leadership to the Utilization Review Committee. Provides operational leadership of regulatory requirements for discharge planning, readmission reduction and reporting for quality metrics. Updates the Utilization Review plan for the organization as required.

ESSENTIAL JOB FUNCTIONS

• Oversight of EHR (Executive Health Resources) referrals and usage.
• Responsibility for the following functions:
  • Utilization Review
  • Care Coordination
  • Discharge Planning
  • Denials Management
  • Access Case Management
• Management of qualifications, competencies, staffing levels, workload and productivity, regulatory compliance, continuing education, performance evaluations, and onboarding process within the department
• Builds program collaboration with physician in areas of discharge planning and utilization review to allow continuous improvement in practices and ongoing education with medical necessity standards.
• Maintenance of systems, processes and education to improve customer satisfaction and SMH outcomes
• Expertise in application of CMS Conditions of Participations and other regulations and standards for the Joint Commission and consistently updates the Department accordingly
• Review Medical Management data for trends and opportunities for improvement
  • Review current processes regularly to ensure maximum efficiency and effectiveness, including but are not limited to:
    • Length of stay
    • Long-stay patients
    • Readmissions
    • Denials
    • Medicare Beneficiary Notice Compliance
    • Condition Code 44 compliance
    • Patient choice compliance
    • Avoidable day compliance
• Shows initiative by suggesting improvements using innovative and creative problem-solving abilities.
  • Provides coaching and mentoring to others to achieve department goals.
• Re-evaluates department data and assesses the success of department plans, constantly makes suggestions and revises the department's goals and plans as necessary to adjust to changing healthcare rules and regulations.
• Displays role-modeling behavior.
• Exhibits clear, open and honest communication with others.
• Establishes and maintains effective relationships with department heads, nursing managers and administrators and administrative staff
• Oversee the development and compliance with departmental policies and procedures.
• Review all readmissions per conditions of participation, collaborating with physicians as appropriate in the review.
• Actively participates in the UM Committee, leading the presentation of data and metrics including but not limited to:
  • Utilization
  • Readmissions
  • Quality
  • LOS
  • Opportunities for improvement.
  • Outlier case review per the utilization management plan.
  • Collaboration in the development of the utilization management annual plan.
• Analyzes and presents departmental metrics explaining all variances and presenting opportunities for improvement.
• Provides data for quality council and other requests to measure ongoing performance in meeting departmental and organizational metrics.

Leadership and Human Resource Management

Demonstrates consistent leadership performance and behavior by actively being engaged in making SMH/BHHN a five-star provider of quality care by being a positive force within the organization and actively promoting teamwork and harmony. Delegates effectively and supervise follow-through. Persuasive, fair, impartial, sets high standards, and ensures clear focus and direction. Achieves desired results with support, confidence and integrity. Regularly recognizes the achievements of others. Leads others to success, supporting individual and team accomplishments.

Supervisory duties and responsibilities include:

• Writes and conducts annual performance appraisals and ensures regular ongoing feedback, coaching, and communication with staff.
• Ensures a high level of performance standards and achievement to meet organizational needs and business goals.
• Provides development opportunities for staff to broaden and enhance their skills and abilities.
• Administers organizational policies and procedures.
• Ensures compliance with safety policies and good housekeeping.
• Manages initial training of new employees and ongoing training as required.
• Promotes an environment that fosters team work and commitment to satisfying customer requirements.
• Ensures appropriate coverage of all areas of responsibility, to include covering responsibilities as needed.

POSITION QUALIFICATIONS

Education / Experience / License and Certifications

• Related degree in appropriate professional areas, including but not limited to:
  • Nursing: Bachelor's Degree in Nursing required; Master's Degree preferred.
  • Social Work: Masters in Social Work required
• Minimum of 3 years supervisory experience, preferred.
• Minimum 3-5 years of hospital Case Management/discharge planning and/or utilization management, strongly preferred.
• BLS, required.
• Behavioral deescalation training within 1 year.

Additional Skills

• Basic computer knowledge
• Proficient in the use of Lean management practices.
• Excellent written and verbal communication; proficient use of the English language.
• Exercises a high degree of initiative, judgment, and discretion.
• Demonstrates solid abilities to analyze situations accurately and take effective action.
• Establishes and maintains effective work relationships, establishing and maintaining effective working relationships.
• Proficient in organizing work, delegating and achieving goals and objectives.
• Demonstrates high level of judgment and discretion in developing, interpreting, and implementing policies and procedures.
• Works effectively with physicians, other medical staff, and external agencies. Demonstrates excellent customer relations skills.

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products.

Pre-employment drug and alcohol screening is required.