Department
UM

Reports to
Chief Financial Officer

Type
Full Time, Exempt

Requisition #
12426

Position Summary

The primary focus of this position is to oversee and coordinate the discharge planning and utilization management activities for assigned caseload.
The Director of Case Management, using established guidelines, performs on-site assessments and utilization review for assigned caseload to facilitate appropriate utilization of resources and efficient patient progression through the continuum of health care resulting in the highest quality and most cost-effective care. The Director of Case Management understands, effectively communicates, and ensures conformity to payer’s requirements. The Director of Case Management identifies, plans, coordinates, and implements high quality, cost-effective alternatives to more costly care, when appropriate to the patient’s condition. The Director of Case Management supports physician decision-making, and works collaboratively with all members of the health care team, the patient, the patient’s family, and internal and external customers to achieve optimal patient outcomes.

Essential Duties and Responsibilities

• Performs utilization review on assigned caseload to assure appropriateness of admission, continued stay, and discharge using established guidelines.
• Assures appropriate utilization of resources that favorably influences the payer but does not compromise quality of care.
• Collaborates with the hospitalist and identifies, coordinates and implements high quality alternatives to more costly care by focusing on the continuum of care.
• Collaborates with all members of the health team, including patient and family to assure their participation and satisfaction, with post discharge arrangements.
• Collaborates with clinical social services in complex cases, providing or seeking assistance to improve the overall utilization/discharge plan for the patient.
• Develops and maintains harmonious working relations with other departments; addresses interdepartmental utilization issues.
• Coordinates the integration of the utilization management functions with other aspects of the overall patient care plans. Assures referrals are complete and benefits verified.
• Initiates decertifications/downgrades of inappropriate admissions and continued stays. Delivers written notification to the patient, family members and members of the health care team as appropriate.
• Regularly communicates with the Chief Nursing Officer, hospitalist, and/or primary care physician for support, problem resolution and for approval for downgrade and decertification.
• Collects, aggregates, and prepares statistical reports and quality information, such as delays in service, possible avoidable days, readmissions, LOS, etc. for presentation to the Performance Improvement Committee.
• Participates in the establishment and maintenance of effective working relationships with the care management team, appropriate community service organizations and public agencies.
• Performs casework and counseling activities and participates in related educational programs for other professional personnel through formal and information instruction.
• Assist in development and implementation of hospital policies in relation to utilization management.
• Adhere to established personnel practices and values of the facility.
• Complies with CHA Compliance Handbook including Code of Ethics and all statues, regulations and guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statues, agreements of guidelines applicable to all healthcare programs

Qualifications

To perform this job with competence, an individual must be able to perform each essential duty as noted above satisfactorily. The requirements listed below are representative of the knowledge, demands, skills and/or ability required.

• Current State of California Registered Nurse License, or Masters of Social Work with licensure as required by state regulations or Masters degree in healthcare administration, business administration or clinical specialty
• High School Diploma or GED, preferred
• Minimum two years’ experience in an acute care setting preferred
• Utilization Management/Case Management experience preferred, with advanced knowledge in options to hospitalization, community culture and resources, entitlement, and reimbursement issues beneficial.
• Working knowledge of Word, and Excel / Access
• Bilingual – Cantonese preferred

Physical Requirements

While performing the duties of this job, staff is regularly required to sit, stand, walk, talk, and/or listen. He/she uses his/her hands to do computer work, write reports, do equipment set-up/cleaning/storage, clerical support, etc. He/she will be using the phone frequently. Good vision is needed to be able to read schedules, enter accurate data, etc. He/she must have good general health and demonstrate emotional stability so as to carry out the above-enumerated duties.

• Able to lift up to 30 pounds.
• Stand, walk, and move 50% of the day.
• Use proper body mechanics when handling equipment.

Compliance Requirements

Complies with Chinese Hospital Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.
I have read and understand the duties, responsibilities, and expectations pertaining to the position. I understand that this job description is intended to describe the general nature and level of work performed. It is not intended to serve as an exhaustive list of all duties, skills and responsibilities required. I have been allowed to clarify and ask questions about this job description.

Base Pay Scale

Starting at $156,125 – $234,000 per year. The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

Job Type: Full-time

Pay: $156,125.00 - $234,000.00 per year

Work Location: In person