Director Case Management

PURPOSE OF POSITION :

The Director of Case Management is responsible for planning, directing, and managing of the activities of the Case Management Program for Signature Healthcare (SHC)”. The responsibilities include the development and supervision of staff (RNs, LPN’s,SWs and non-clinical support), evaluation and maintenance of case management skills and outcomes, management of all policies and procedures, and ensuri ng adherence to the key model components that drive outcomes. Customers include patients, patient’s families, visitors, nursing staff, physicians, interdisciplinary team members and accrediting bodies. Works collaboratively with the multidisciplinary team to assure quality, timely and cost efficient care.

Develops, implements and evaluates the strategic plan for the organization-wide Case Management system and process for all services across Signature Healthcare. Provides operational supervision of the Case Managers, Social workers and supports ongoing problem solving. Establishes tools, processes and systems to optimize all roles. This position has significant impact on patient care revenue and expense and provides mission critical access to Hospital & Signature Medical Group. Collaborates with all disciplines with a specific focus on tangible outcomes related to improved quality, patient / provider satisfaction and revenue management. Provide high-level support & direction to case management staff and Social workers and supports ongoing problem solving.

INDEPENDENT ACTION :

Functions independently within the scope of the defined role. Establishes short and long-range plans and objectives. Actively solves problems, referring exceptional issues to Vice President.

The Director of Case Management is responsible for planning, directing, and managing of the activities of the Case Management Program for Signature Healthcare & Signature Medical Group

The responsibilities include the development and supervision of staff (RNs, LPN’s, SWs and non-clinical support), evaluation and maintenance of case management skills and outcomes, management of all policies and procedures, and ensuring adherence to the key model components that drive outcomes

Customers include patients, patient’s families, visitors, nursing staff, physicians, interdisciplinary team members and accrediting bodies

Works collaboratively with the multidisciplinary team to assure quality, timely and cost efficient care

Demonstrates appropriate communication skills for the patient population served and other SHC customers

Demonstrates leadership in the change process

Provides coordinated care support to facilitate and expedite patient care services. Participates in daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include preadmission and post hospital discharge. As a member of that team shares responsibility for the implementation of the discharge plan; ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources.

Participates in daily care rounds to collaborate with members of the patient's healthcare team as well as to evaluate and facilitate development and implementation of the discharge planning process. Develops the initial patient discharge plan and reviews with patient family members and other members of the interdisciplinary team. Reassesses the discharge plan daily during collaborative care rounds.

Proactively builds post hospital referrals and sends to the Transition Care Coordinator when indicated to facilitate timely discharge.

Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through problem resolution and follow-up.

Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare Hospital standards, prompt notification of denials, questionable cases and cases referred for outside review.

Monitors denial rate and develops remediation plans to address common sources of denials.

Assists in education of staff and community physicians on utilization issues. Participates in meetings with payors and JV partners.

Facilitates professional development and continuing education for all case management staff.

Plans, develops and implements a case management program that enhances the quality of patient care while optimizing resource utilization.

Provides training to staff on case management methods and techniques.

Establishes monitoring mechanisms to identify areas for improvement of resource utilization.

Plans and develops systems and processes in response to payor requirements.

Monitors payor denials, identifying patterns and trends. Develops actions plans and responses for the reduction of payor denials.

Utilizing an array of information systems, plans and develops reports that clearly monitor all areas of utilization / case management.

Provides data, guidance and input on the development and monitoring of the Care Maps project.

Acts as liaison with payors and external review agencies, to coordinate activities involved in medical record review, denials, appeals and reconsideration hearings.

Works closely with the physician advisor to proactively intervene in cases where utilization of resources is sub optimal.

Aggregates information for an array of audiences which demonstrates how Hospital resources are being utilized.

Assists with preparation of department budget.

Prepares and presents information of resource utilization to the Quality Improvement Committee.

Develops / leads teams in response to identified opportunities in resource utilization. Reports the results of team activities to the Quality Improvement Committee.

Works collaboratively with Nursing and Social Work to ensure that discharge-planning activities are appropriate, comprehensive and effective.

Works collaboratively with Finance to ensure that information required for reimbursement is timely and accurate.

Performs other duties as required or assigned.

SUPERVISORY RESPONSIBILITY :

Directly manages the case management team at Brockton Hospital and Signature Medical Group

QUALIFICATION REQUIREMENTS :

Must have strong analytical abilities to strategically plan, consensus build and problem solve

Demonstrates appropriate judgment in decision making

Must be able to communicate and convey complex information in a professional and courteous manner

Must have administrative skills to supervise and develop staff, plan, organize, direct, and evaluate

Must have proficiency in data analytics

Must have strong understanding of clinical and financial outcomes

Must have strong interpersonal skills

Must have ability to interact effectively with a wide range of personalities, ages, and diverse cultural backgrounds

Must be able to work in a fast paced environment and demonstrate performance agility in a continuously changing environment

Good visual, verbal, hearing skills

Fluent in English

Proficiency in using computers and ability to quickly gain competency in various software applications, including hospital specific applications, Microsoft Office, cell phone, pager

To perform this job successfully, an individual must be able to meet expectations relative to the purpose of the position and perform each primary responsibility satisfactorily. The requirements listed below are representative of the knowledge, skill, education, experience, and / or ability to perform this position successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the primary responsibilities.

EDUCATION :

RN with Master’s Degree

Current License as Registered Nurse in the Commonwealth of Massachusetts

EXPOSURE CATEGORY :

It is reasonable to anticipate that the incumbent may have occupational exposure to blood borne pathogens in the course of his / her regularly scheduled activities as associate of SHC Brockton Hospital and Signature Medical Group

BASIC KNOWLEDGE / SKILLS / APTITUDE AND EXPERIENCE :

Minimum 5+ years of progressive management experience with demonstrated goal oriented outcomes

Minimum 7 years acute clinical experience

• Must have demonstrated leadership and change management experience

Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience required. A “hands on”, visual, team builder and effective communicator style is key to the success of this position. Knowledge of payer requirements and regulations that support and effect development of departmental policies, procedures and standards. Demonstrated ability to establish goals, vision and overall direction of the department; create and implement departmental standards, systems, staffing plan and processes; analyze issues and create effective plan to address them; critically and comprehensively evaluate the departments outcomes; identify, collect and analyze data related to the internal and external environment as well as departmental functioning; and develop and educate staff. Demonstrated ability to communicate verbally and in writing to internal and external customers. Knowledge of external requirements that impact the department, such as The Joint Commission (TJC),CMS, and The Department of Public Health. Ability to understand and interpret medical records, hospital bills and have a clear understanding of ancillary department functions.

REASONING / COMMUNICATION SKILLS :

Must have strong analytical abilities to strategically plan, consensus build and problem solve. Demonstrates appropriate judgment in decision making. Must be able to communicate and convey complex information in a professional and courteous manner. Must have administrative skills to supervise and develop staff, plan, organize, direct, and evaluate. Must have proficiency in data analytics. Must have strong understanding of clinical and financial outcomes. Must have strong interpersonal skills. Must have ability to interact effectively with a wide range of personalities, ages, and diverse cultural backgrounds. Demonstrates appropriate communication skills for the patient population served and other SHC customers. Must be able to work in a fast paced environment and demonstrate performance agility in a continuously changing environment. Demonstrates leadership in the change process. Good visual, verbal, hearing skills. Fluent in English. Proficiency in using computers and ability to quickly gain competency in various software applications, including hospital specific applications, Microsoft Office, cell phone, pager.

Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization may exist. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Must be able to reasonably make appropriate judgment in communications and actions with patients, physicians, other associates, outside agencies, and vendors.