Works with the Director and Case Management Staff to develop, implement, and sustain the Care Management process for Resource Utilization designed to prepare for increasing managed care environments and expectations. Design and analysis of utilization opportunities, development of strategies to decrease utilization, development of staff to coordinate patient admissions and discharges, collaboration with physicians to change practice patterns, and negotiation with payor for certified days of care.

Responsibilities

• Manages the Care Management department activities by participating in the planning and development of goals and objectives, establishes and implements policy and procedures for TJC surveys to endure the Utilization Program meets regulatory standards, laws, and the Medical Center Mission and goals. Maintains working knowledge of TJC standards and their interpretations as related to areas of responsibility. • Prepare reports, as directed, concerning department activities. • Encourage professional growth of staff. • Assist in the supervision and evaluation of personnel and other department personnel as necessary. • Interpret and administer hospital personnel policies as they affect personnel. • Oversee the day to day management/supervision of the discharge planning process with unit focus on decreasing LOS. • Coordinate with nursing department staff and managers to ensure combined commitment and understanding to effective d/c planning processes. • Assume responsibility for assigned areas. Organize these areas consistent with the total Service Line organizational structure. • Scheduling of employees as it relates to the needs of the organization, reimbursement and other processes. Personnel Resource Management. • Manage contracting with outside agencies. • Manage denials through multiple avenues, such as, denial meeting, payor assistants, outside agencies, and patient accounts. Develop reports to trend denials for process improvement. • Oversee proper classification of patients across the hospitals to ensure accuracy using Interqual and guidelines set forth by the government. • Educate physicians regarding proper status placement at admission. • Make rounds to educate and ensure case management staff are following processes that adhere to standard/department policy. • Continual education with case management staff on payor updates, interqual, documentation and other process changes. • Maintain department, institution, and licensure (if applicable) required education. Document appropriately. • Responsible for integrating continuous, quality improvement into department and institution operations, and demonstrate a commitment to the process. • Reinforce employee understanding of work integration with other departments throughout the institution. • Assure appropriate employee orientation by qualified personnel and assure personnel follow through with timely flow of information. • Exhibit professional behavior & serve as an effective role model through appearance, attendance, commitment, and competence.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.

Education

• Bachelor's Degree (Required) Education: Degree may also be in related field Experience: 5-7 Years - Combined Experience to Include at Least 5 Years Professional Nursing, and Applicable Experience in Utilization Review and Supervisory/Mgmt Areas.

• Bachelor's Degree (Required) Education: or Bachelor Degree - Related Degree Experience: 5 - 7 Years - Combined Experience to Include at Least 5 Years Professional Nursing, and Applicable Experience in Case Management, and/or Utilization Review, Supervisory/Management of Case Management and/or Utilization Management Team , Minimum of 1 year in quality assurance/quality improvement and Experience with MCG and/or InterQual, and other evidenced-based guidelines for utilization management and case coordination Education: or Bachelor Degree - Related Degree Experience: 5 - 7 Years - Combined Experience to Include at Least 5 Years Professional Nursing, and Applicable Experience in Case Management, and/or Utilization Review, Supervisory/Management of Case Management and/or Utilization Management Team , Minimum of 1 year in quality assurance/quality improvement and Experience with MCG and/or InterQual, and other evidenced-based guidelines for utilization management and case coordination

Credentials

• Registered Nurse (Required)

Work Schedule: Days

Status: Full Time Regular

Location: General Hospital

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@camc.org