Oversees hospital utilization performance improvement and operational management of the site Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.
Integrates national standards for case management scope of services including:
• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to physicians, patients, families, and caregivers
Responsibilities include the following activities: a) manages department operations to assure effective throughput and reimbursement for services provided, b) leads the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensures medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensures timely and effective patient transition and planning to support efficient patient throughput, e) implements and monitors processes to prevent payer disputes, f) develops and provides physician education and feedback on hospital utilization, g) ensures compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.
Drafts policy provisions and provides interpretation of department policies, in accordance with the DMC Utilization Review Plan. Identifies the need for and drafts or defines procedures/protocols in collaboration with higher management input, goals, and objectives; modifies procedures/protocols, as necessary. Monitors the quality and productivity of staff to ensure work is completed. Implements performance improvement activities to insure consistency and safety within departmental activities. Initiates or recommends personnel actions such as hires, fires, disciplines, etc. Completes performance appraisals and ensures competency of staff. Assists in the development of daily, monthly, and/or yearly goals and measures for department, and as requested, assists in assessment of goal attainment. Assists in developing and monitoring budget. Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and DMC policies relating to areas of responsibility. As directed, implements external and internal audit recommendations.
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
• Ensures new case management staff complete department orientation including review of Tenet Case Management and Compliance policies and Allscripts training.
• Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent, and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.
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
• Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends, and educating hospital and medical staff on actionable items
• Implements and monitors physician "peer to peer" review process with payers to resolve denials or downgrades concurrently.
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Monitors, analyzes, and reports Avoidable Days using the data to address opportunities for improvement
• Participates and/or serves as lead for hospital Medicare Performance Improvement (MPI) initiatives.
• Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
• Monitors to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
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
• Identifies and reports variances in appropriateness of medical care provided over/under utilization of resources compared to evidence-based practice and external requirements.
• Monitors to ensure case management staff document in the Tenet Case Management system to communicating information through clear, complete, and concise documentation
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 relevant to the
oEffective progression of care,
oAppropriate level of care, and
oSafe and timely patient transition
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
• Implements and monitors compliance with Tenet Case Management practices
Minimum Qualifications
1.Bachelor's degree in Nursing or other health-related field, or the equivalent combination of education and/or related experience or Master's in Social Work for MSW. Master's degree in Nursing, Business Administration or Hospital Administration preferred.
2.Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.
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.
