Status: Full Time
Shift: Varies - Exempt
Exempt: Yes
Other information:
Previous Experience:
Minimum of 5 years nursing experience with a minimum of 3 years inpatient/observation patient care required.
A minimum of 3 years of management experience required.
3 years of experience related to Discharge Planning, Case Management or Social Services, Utilization Management/Case Management experience preferred.
Specialized or Technical Education
Registered Nurse with unrestricted license to practice in the State of Louisiana. BSN required, Masters Degree preferred.
Knowledge of Prospective Payment System, DRG's, other payment methodologies, Fiscal Intermediaries, Peer Review Organizations, Referral Agencies, and Community Resources necessary.
Basic knowledge of ICD-10-CM coding and CPT coding required. Previous Case Management Department management preferred.
Knowledge of Legal Compliance issues and how they relate to the Case Management Department are necessary.
Knowledge of Quality Assessment/Performance Improvement activities and procedures preferred.
Physical Effort Required/Physical Demands:
Strength: Light
Push: Occasionally
Pull: Occasionally
Carry: Occasionally
Lift: Occasionally
Sit: Frequently
Stand: Frequently
Walk: Frequently
Responsibilities:
Implements the Case Management Program for North Oaks Health System.
Develops / revises the mission statement, goals and objectives for the Case Management Program (Care Management, Social Services, and Discharge Planning) that meet clinical and financial requirements.
Interprets and implements the Centers of Medicare and Medicaid Services (CMS) Conditions of Participation, Managed Care, The Joint Commission and Comprehensive Acute Rehabilitation Facility (CARF) standards and functions relevant to coordination of care.
Anticipates, evaluates, recommends, and implements policies and procedures related to the Care Management program, including appropriate resource utilization, identification of avoidable days, community resource utilization, and discharge planning.
Also assists the Clinical Documentation Specialists to manage the Clinical Documentation Management Program.
Works closely with Revenue Cycle departments to prevent and respond to denials and contributes to denials management program for the system.
Maintains departmental budgets and monitors monthly variance reports to ensure operations are within budgeted guidelines.
Works in a team environment to manage the total function of the Case Management Department.
Reports on Case Management quality indicators, payor-specific updates, and second level review cases to the VP of HHS, Sr. VP of Clinical Services/CNO, Chief Medical Officer, and Medical Staff at least on a quarterly basis.
Oversees and assists the Utilization and Denials Manager with all aspects of Utilization & Denials Management including development of policies, and procedures, coordination of activities with other Revenue Cycle departments, and management of payer relationships.
Provides orientation and in-service training on the Case Management Department to new employees, Physicians and others as needed.
Ensures that all Case Management employees are informed about available resources used in care management and discharge planning.
Interfaces with and coordinates efforts of Admissions, Patient Financial Services, Health Information Services, Finance, Rehabilitation Services, Risk Management, Legal Compliance, Quality Performance, and other ancillary departments as needed, relevant to the Case Management program.
Directs, plans and coordinates all inpatient or observations hospital case management, and utilization review activities as assigned, by working closely with hospital interdisciplinary teams to provide positive patient outcomes.
Assists with the education of members of the Medical Staff as needed on utilization, case management, discharge planning, payor-specific rules and regulations, and documentation requirements.
Actively participates in the development of clinical guidelines and incorporates those processes into the role of the Care Manager.
Interfaces with external agencies (e.g., home health agencies, skilled nursing facilities, rehabilitation facilities, nursing homes, durable medical equipment companies, EQ Health Solutions (QIO), third-party quality improvement organizations, Tangipahoa Social Service Coalition Tangipahoa CARES Advisory Board, Tangi Medical Managers Association, area universities [internship programs] and other hospitals).
Provides appropriate information, consultation, or recommendations to staff members on interactions with such agencies.
Maintains current knowledge of trends in case management and recommends changes as needed to maintain a state-of-the-art case management program.
Maintains daily working knowledge of in-house cases and knows discharge plan for any patient with extended length of stay and facilitates interdisciplinary team meetings, observation, and inpatient huddles.
Informs the leadership of any concerns, activities, and ideas for improvement for the Case Management and Utilization Review departments Provides Direct Supervision and Management of Staff Provides direct supervision for Utilization and Denials Manager, RN Care Managers, Patient Flow Navigator Nurse RNs, ER Case Managers, Social Workers, office staff, and junior volunteers Performs annual appraisals of employee performance as stated above.
Determine staffing levels and approve time off requests for department employees supervised.
Participates in Quality Improvement Activities.
Supports culture of continuous improvement. Demonstrates ability to work within a team structure. Contributes to team goals and objectives supporting organizational and departmental strategic plans. Actively participates in consensus building on work team. Serves as team leader and/or facilitator on quality improvement teams. Uses quality improvement tools and strategies in problem-solving activities.
Maintains strict confidentiality regarding patients, employees, and medical staff issues.
Completes ongoing review of departmental policy and procedure manual, Quality Improvement Plan of Care to maintain current status.
Consults with and provides information as requested to payors.
Assists with the appeal process for all denied inpatient and observation claims.
Actively participates on Medical Staff Steering Committees, Nurse Management Committee, Performance Committee, Hospital-Area Nursing Home Committee, Managed Care Contract committee, Chargemaster Committee, Rehab Team, and various other system-wide CQI teams.
Oversees internship program for RN Care Management and Social Work undergraduate and graduate programs.
Responsible for policy, procedure, and staff development, Medical Staff education, ongoing monitoring and reporting progress of the Clinical Documentation Management Program.
Performs all other duties as assigned.