Summary
JOB DESCRIPTION
Provides day- to day operational leadership, oversight, and support to the Acute Case Managers, nurse utilization management team, medical social workers and administrative staff. Leads, and facilitates in utilizing current practice and process to achieve optimal patient, clinical, and operational outcomes in timely, coordinated, and cost- effective manner. The Manager-of Case Management supports utilization management, discharge planning, denial prevention, and care coordination scope of practice within the department. The Manager-Case Management collaborates cooperatively with members of the interdisciplinary health care team, the patient, community health care providers, and third- party payers to assist in ensuring that the patient receives the needed services in a timely manner in the most cost-effective setting.
Qualifications
A minimum of two years Acute Case Manager experience; 2 years of experience in a supervisory or lead role.
Education
Bachelors degree in nursing is required. Must successfully obtain/maintain a pass rate of at least eighty percent upon orientation completion and each year thereafter, of an established inter-rater reliability tool such as InterQual.
Knowledge, Skills And Abilities
- Demonstrated capacity to lead projects and teams
- Demonstrated effective verbal and written communication skills
- Knowledge and experience with payors, CMS guidelines, TJC, EMTALA other regulatory agencies
- Demonstrated strong communication and customer service skills, problem solving, critical thinking, and clinical judgement abilities
- Experience with Electronic Health Record (EHR)and case management applications
- Proficient computer skills including Microsoft Office (Word, Outlook, Excel, PowerPoint)
- Proficient with medical necessity criteria including InterQual, Milliman guidelines
- Strong managerial skills, including coaching, mentoring conflict resolution and motivational skills
- Understanding of care planning interventions which includes but not limited to care coordination, nursing assessment and biopsychosocial assessment
- Exceptional interpersonal skills required for connecting with patients and their family as well as successfully interacting with referring physicians and community organizations
License:
Essential Functions:
- Effectively, guides, leads, and mentors the team to attain organizational goals and initiatives
- Supports and assists with ensuring that the right care is provided to patients in the right setting, by the right providers, at the right time
- Manages and assumes responsibility for day-to-day operations of utilization management, care coordination, and discharge planning activities
- Develops and provides statistical UM information and reports to the appropriate committees in conjunction with committee chair
- Works closely with Physician Advisors, attendings, residents and other members of the healthcare team to provide appropriate resource utilization and application of medical necessity criteria
- Coordinates medical management through ongoing interaction with the patient and family/caregivers, physician and other health care providers to achieve designated clinical, operational and financial outcomes.
- Facilitates clinically appropriate treatment and coordinates flow of services by acting as a focal point for communication for healthcare team members, patient, provider, and payer
- Supports development, integration, and monitoring of clinical pathways and guidelines
- Maintains accountability for coordination of care processes for the patient during the acute care phase, and during the transition phase to outpatient services
- Initiates and participates in patient care conferences as appropriate
- Provides leadership for clinical staff regarding complex patient care concerns and/or care of patients who do not achieve expected outcomes
- Integrates patient information, clinical/financial/operational data and evaluates the impact upon patient, clinical, and financial outcomes. Identifies opportunities to continue or reduce costs and optimize case reimbursement.
- Identifies cost/clinical outlier patients for intensive case management and facilitates evaluation of alternative care options
- Ensures compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies
- Participates in long-range planning to meet the needs high risk patients and/or population
- Develops and promotes collaborative relationships with other members of the Guthrie healthcare community resources, including home health agencies, DME companies, nursing homes, etc., to explore alternate care options to meet identified patient care needs
- Participates in performance improvement and educational activities.
- Incorporates available current evidence-based data for clinical care management
- Serves as an educational resource for other members of the healthcare team in regard to changes in reimbursement and /or utilization requirements
- Maintains 8 hours of continuing education per year
- Ensures variance days are tracked and trended for LOS improvements
- Contributes to Performance Improvement (PI) activities through both individual and aggregate data monitoring. Initiates and provides leadership for performance improvement activities as appropriate based upon outcome data and or problematic issues
- Conducts periodic audits to ensure policies and procedures are followed and serve as a clinical consultant regarding case management issues
Other Duties
It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.
About Us
Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.
The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.
The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.
