Manager Care Management

Job Summary

The Manager of Care Management is responsible for the development, planning, coordination and administration of the activities of Utilization Review and Discharge Planning. Responsibilities include, but are not limited to daily review of medical records to determine appropriateness and medical necessity of admission as well as continued hospital stay and use of diagnostic services.

Essential Functions

• Case manages high volume, high lengths of stay, high risk, and high cost patients. Utilizes census report to prioritize workload daily.
• Prioritizes workload based on LOS, DRG, charges, and payor reimbursement.
• Monitors patient's progress to ensure care is streamlined, appropriate, and timely.
• Evaluates patients through chart review, physician and nurse interview, and patient assessment within one working day of admission. Performs clinical/psychosocial assessment.
• Establishes expected daily and stay clinical outcomes.
• Initiates plan of care/triggers and reviews with staff within one working day of admission.
• Responsible for managing the daily operations of the department. Organizes department hierarchy/structure in a manner that results in efficiency, effectiveness, and responsiveness.
• Establishes short and long term goals in order to be consistent with NHS and CHS goals.
• Appropriately delegates while maintaining responsibility and accountability for delegated tasks.
• Responsible for staff performance, recruitment, retention and staff development.
• Improves subordinate performance through on-going counseling, coaching, delegation, and feedback practices and monitors threat standards are consistently being met.
• Interacts with physicians, nurses, and other healthcare team members to facilitate plan of care. Serves as resource for physicians and staff regarding patient progress.
• Participates in physician rounds, discharge planning meetings and patient care conferences.
• Oversees the function of case management including performance improvement, case management to ensure that patient care is appropriate, timely, cost effective, and achieves desired outcomes.
• Assists in coordination of ancillary services: ensures actions are taken on all orders and intervenes with other departments to obtain services when necessary.
• Performs Resource Utilization on all patients to reduce inefficiency/cost: Evaluates over-utilization/under-utilization and follows-up with physician.
• Monitors observation stays: ensures timely admission or discharge within 24 hours. Utilizes HBOC report to monitor outpatient stays daily.
• Improves and monitors quality of care: identifies and documents variance from expected outcome for each case. Assembles variances and reports to supervisor in timely manner.
• Works effectively with pre-certification nurse to ensure pre-authorization of insurance: Provides clinical information to insurance/pre-cert within 24 hours of notification.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Associate Degree Graduate of an accredited RN program from accredited Nursing program. required
• Bachelor's Degree BSN preferred
• 2-4 years in nursing or home health with excellent communication required
• 2-4 years experience in case management or utilization management preferred

Knowledge, Skills and Abilities

• Skills and ability to work collaboratively with all members of the healthcare team.
• Strong analytical and problem-solving skills
• Ability to produce accurate and comprehensive work products with minimal direction.
• Strong clinical expertise in critical care nursing practices and standards.
• Ability to effectively communicate to all levels of the facility including staff, physicians and senior leadership
• Ability to acquire, evaluate, and report information accurately.
• Ability to convey information in a clear, concise, and logical manner.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Current Missouri or compact state registered nurse licensure required