Southwest Region -Texas, New Mexico, Arizona and Oklahoma locations 

Job Summary

Responsible for the development, implementation and/or monitoring of the Region case management program, including related training and consulting with facility case managers, Region and facility management and physicians, as needed. Works closely with the VP, Clinical Operations, Regional CNO, and Region Case Management teams to ensure that the case management program complies with standard treatment protocols and lengths of stay for diagnosis-related groupings (“DRG”) for patients in long term acute care facilities. Assures that the case management program provides for and ensures that appropriate and cost effective medical, medically-related social services and behavioral health services are identified, planned, obtained and monitored for individuals eligible for long term acute care health services.

Essential Functions

Leadership

• Participates in planning and developing the Region’s and hospitals’ strategic, operational, service designs and other organizational plans and policies to achieve the mission and vision of the Region and hospitals.
• Plans and develops financial plans, including budgets, revenue projections, capital requirements and operational expenses, sufficient number of staff, and any other plans for allocation of fiscal or other resources according to the scope of services provided.
• Collaborates with VP, Clinical Operations to advance Case Management strategies across the Division.
• Develops, designs, and provides for a written scope of services, policies and procedures that guide and support the provision and integration of services according to mission and vision of the Region and the Region hospitals. Works within the policy structure of the company.
• Directs the coordination and integration of services with other departments and the primary functions of the Region hospitals.
• Communicates the Division’s, Region’s mission, vision, and goals to staff and motivates Region and hospital staff to implement supporting operational, programmatic, and other plans.
• Recommends and determines the sufficient number of staff to provide services and defines qualifications, performance expectations and competence of each person.
• Provides orientation, in-service training, continuing education, annual performance, and competency reviews of department personnel to ensure staff is competent to provide services.
• Participates in performance improvement activities to measure and assess the quality of services provided.

Job Specific

• Oversees region case management program and implements appropriate monitoring mechanisms to assure programs are compliant with the Corporate Compliance Agreement. Program.
• Collaborates with Region’s facility case managers in development, implementation and monitoring of effectiveness of hospital division case management program and utilization management plan.
• Works with Division, Region, and hospital management staff to establish short and long-term strategic planning goals for case management program.
• Designs, implements, and monitors process to ensure appropriate authorizations or determinations of medical necessity for all payor sources and facilitates collaboration with hospital staff with the goal of decreasing payor denials or non-medically necessary days at the facility level. Advocates for the patient’s right to utilize LTAC and other services as appropriate.
• Identifies opportunities to improve average length of stay and optimal discharge timing.
• Designs, implements, and monitors clinical processes to assure optimal clinical progression of the patient, utilization of resources and reimbursement.
• Ensures that standards of case management practice and integrated services are developed that are consistent with professional standards and regulatory requirements.
• Anticipates, evaluates, proposes, and implements opportunities to use new technology for performance and productivity gains.
• Assesses learning needs related to case management practice (divisional, Region and facility) and implements appropriate educational activities to expand knowledge base. Ensures that training modules meet specified learning needs.
• Serves as consultative resource for facilities regarding complex discharge management.
• Ensures that reports are available for optimal case management function as available in ScionHealth’s IT infrastructure.
• Reviews financial chart audit data to assist in ensuring correct billing practices.
• Researches and recommends appropriate case management model, including established care plans by DRG.
• Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.
• Promotes adherence to the Company's Code of Business Conduct and the Corporate Compliance Agreement by monitoring performance and identifying and responding to compliance issues.

Company Specific

• Adheres to dress code, appearance is neat and clean and wears appropriate identification when appropriate.
• Completes annual health, safety, and education requirements. Maintains professional growth and development.
• Maintains confidentiality of all patients and/or employee information to assure patient and/or employee rights are protected.
• Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age-appropriate care to the patient population served.
• Reports to work on time as scheduled; adheres to policies regarding notification of absence.
• Attends all mandatory management and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the Company, Division and Region.
• Maintains current licensure/certification for position, if applicable.
• Consistently demonstrates Guest Relation’s skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows Company, Division and Region Health, Safety, Security, Hazardous Materials policies, and procedures.

Knowledge/Skills/Abilities/Expectations

• Basic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software.
• Extensive background and knowledge of hospital-based case management, utilization management and discharge planning.
• Knowledge of Medicare benefits and insurance processes and contracts.
• Excellent interpersonal, verbal, and written skills in order to communicate effectively and to obtain cooperation/collaboration from division, Region, and facility management, as well as physicians, payors, and other external customers.
• Ability to work independently and effectively with all levels of the organization.
• Ability to maintain confidentiality of all patients and/or employee information to assure patient and/or employee rights are protected.
• Ability to work under stress, often with conflicting priorities, and to respond quickly in emergency situations.
• Ability to work cooperatively and effectively as a team member and as a team leader.

Education

• Bachelor’s degree in nursing or other health-related field required. 
• Master’s degree in nursing or other health-related field preferred.

Licenses/Certification

• Registered Nurse or Licensed Clinical Social Work Case required. 
• Case Management Certification preferred.

Experience

• Minimum of 10 years’ experience in case management or utilization management; including minimum of five years’ experience at case management managerial level.
• Prefer experience in multi-facility healthcare system.
• Experience in case management training required.