Job Description

Job Description

Under the direction of the Chief Financial Officer (CFO), develops, implements and monitors case management goals and objectives relating to clinical/utilization activities as well as the collection and tracking of hospital quality information to facilitate the achievement of desired outcomes, address ongoing needs, maximize patient, family and provider satisfaction, facilitate timely discharge, assure appropriate length of stay, ensure payer authorization and medical necessity requirements are met, and reduce unnecessary delays/other adverse variances to delivery of services.

Evaluates patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards. Seeks treatments that balance clinical and financial concerns with the family's needs and the patient's quality of life.

Demonstrates in-depth analytical and organizational skills in order to lead and coordinate case management functions, effectively develop staff, develop and monitor budget, short and long range planning and solve complex technical and human resource problems to ensure optimal development and maintenance of program services.

Requires knowledge of statistics and data systems to provide leadership in the collection and reporting of clinical and quality data for administrative and medical staff reports.

Requires in-depth knowledge of multidisciplinary care planning, scope of practice and related problem solving, as well as the knowledge and understanding of intensity of service, severity of illness, opportunities for intervention, planned course of treatment/procedures, care needs and outcome goals to provide direction to case management staff in clinical and utilization review activities.

Demonstrates a high level of interpersonal and communication skills, both verbal and written, in order to interact effectively with all internal and external customers.

Leads and directs the work of others. Performs a variety of tasks. A wide degree of creativity and latitude is required.

ESSENTIAL FUNCTIONS:

Score

Function

1. Oversees and provides support for Case Management activities, including Utilization Review, Social Services, Case Management, and Discharge Planning to provide for continuity of patient care in a cost-effective manner.

2. Provides strong leadership for the Case Management department, including hiring and mentoring of staff and administering disciplinary action when necessary. Facilitates working relationships to ensure effective inter- and intra-department cooperation and communication. Develops, reviews and maintains appropriate policies and procedures related to case management and utilization. Manages the expenses of the department in accordance with the budget.

1. 3. Actively participates in the hospital revenue cycle by ensuring all necessary authorizations are obtained from third-party payers and working with the Central Billing Office to track and appeal denials to allow the hospital to be reimbursed for the services to provided to our patients.

4. Collects and analyzes case management data, including but not limited to admission denials, continued stay denials, length of stay, and inappropriate use of resources, to demonstrate effectiveness and identify opportunities for improvement. Analyzes documents and presents utilization data, in a meaningful and useful form, to the Quality Team, UR Committee, Compliance Committee and Administration.

5. Monitors compliance with required CMS forms and completes changes required by CMS and CHS to stay compliant with regulations. Forms/documentation include the Two Midnight Rule, Important Notice, Patient Choice forms, Code 44 and HINN forms. Reports any perceived findings of fraud or abuse to the Director of Compliance. Abides by the hospital code of conduct.

6. Provides oversight and education to the department to comply with standards promulgated by the Joint Commission on Accreditation of Healthcare Organizations (TJC), the Indiana State Department of Health, or any other regulatory agency.

7. Responsible for ensuring an excellent patient experience with regard to transition of care and discharge information. Leads activities to ensure the organizations patient experience goals are achieved.

8. Communicates well with outside agencies (Extended Care Facilities, Insurance carriers, Medicare intermediary, Home Health Care Agencies, etc.). Serves as the Chairperson for the Hospital Readmission Team fostering transitions for patient care and identifying opportunities to improve patient care and prevent readmissions. Provides education to associates and physicians on regulatory requirements concerning admission, continued stay, discharge and transfer of patients, including use of MCG (Milliman) and InterQual criteria.

9. Maintains age appropriate competency skills and knowledge, demonstrates ability to perform skills specific to patient population identified in unit specific skill list:

(Mark age specific of patients served in assigned unit)

_X __ birth to 12 months, _X___ pediatric ages 13 months to 10 years,

_X___ adolescent ages 11- 16 years, _X___ adult ages 17 to 64 years

_X___ geriatric ages 65 and over

10. Works with Department Managers, Directors and the Physician Advisor to identify ways to improve the quality of patient care in a cost-effective manner.

NON-ESSENTIAL FUNCTIONS:

Performs other duties as assigned.

JOB QUALIFICATIONS:

Education and Formal Training Required

1. Minimum of an associates degree in business, allied health or related area; Bachelors and Masters degree in related area a plus.
2. Must have knowledge of and ability to interpret The Joint Commission and Indiana State Department of Health quality review standards.

Experience Required:

1. Must have at least five years clinical experience with progressively increasing responsibility, in the areas of patient care or case management (case management experience preferred).
2. Must have a minimum of two years of management experience.
3. Experience in computer software, including proficient use of Word, Excel, PowerPoint and Microsoft Access experience preferred.

Licensure Required:

Must have a valid Indiana Registered Nurse nursing license.

Other:

Must have excellent verbal and written communication skills to obtain and exchange information with all levels of hospital personnel and outside agencies. Must also have good analytical and organizational skills.

Working Conditions:

Normal office environment with little exposure to dust, excessive noise and extreme temperatures. Has some exposure to infectious diseases.

Has some exposure to blood and body fluids: Exposure Control Level II.