Responsible for the development, implementation and ongoing review of the enterprise wide continuum of care case management integrated system.
Provide leadership and direction to implement the case management plan across the continuum consistent with mission, values, goals and objectives. Scope of the position includes:
Hospital utilization review
Clinical research study coordination
Hospital transition planning/social services functions
Care Coordination Institute (CCI) long term complex case management and risking risk intervention program
Transitional care program
Post-Acute Care Team (PACT) readmission reduction program
Palliative Care Services (inpatient and outpatient)
Hospital based chronic disease management services
Post hospital discharge call back/follow up programsDiabetes Education
Aligned post-acute partner relationships
Other case management programs to be determined based on need
Participate with leaders of the hospitals, medical staff, medical group practices, managed care, Post acute care, community stakeholders and clinical areas to achieve optimal clinical and financial outcomes. Directs and coordinates the planning, organizing, prioritizing, implementation and evaluation of the activities and associates engaged in care management. Assure compliance and oversees the operational processes of case management consistent with regulatory and third party payer requirements and regulations.
Highly engaged with Payors and Value based contracts along with ACO and ACO committees.
Mission: To enhance the physical, mental and emotional well-being of the communities we serve as the community’s provider of outstanding quality, superior value and comprehensive health care services.
Innovative health care and well-being services of the highest quality at the greatest value
Easy access and convenience
Outstanding patient experiences
Ongoing education involving physicians, patients and the community
Through experience have demonstrated flexibility, resilience and ability to be successful with increasing responsibility in dynamic health care environment.
Knowledge & Skills
Understanding of benchmarking, case management concepts, current reimbursement practices and requirements of third party payers and clinical care and disease management practices, procedures and techniques.
Understanding of Medicare, Medicare Advantage and Medicaid programs and third party payer medical policy requirements.
Understanding of and proven ability to reduce LOS and readmission for ACO, Bundled payment programs, Value Based contracts and Value Based purchasing.
Adept in interactions/negotiations with community agencies, services and resources available to assist patients/families with identified needs to meet health goals.
Ability to operationalize the requirements of Milliman and Interqual care guidelines within the department.
Can proactively manage authorization challenges for care being delivered.
Highly effective managerial skills including planning, organizing, delegating, coaching, and facilitating and coordinating staff activities.
Can motivate associates and foster collaboration, creativity and engagement.
Highly developed leadership skills that enable one to make sound decisions, mediate and resolve conflicts between multiple decision-making groups, and handle diverse and complex problems.
High level analytical skills necessary to plan, organize, formulate innovative solutions and compile, analyze and evaluate data and prepare accurate reports.
Broad knowledge and successful leadership in performance improvement activities.
Strong interpersonal skills necessary to promote and maintain cooperative and courteous relationships between individuals with disparate interests.
Advanced, effective communication skills, including verbal, written, and listening skills.
Technological skills and knowledge to successfully utilize hospital computer systems and software programs involved continuum of care case management activities.
Case Management Program Development
In a dynamic healthcare system, establish/continuously improve team structures, responsibilities, and relationships to effectively and efficiently manage medical necessity of admissions to the hospitals, duration of stays, professional services furnished, processes ensuring compliance, community outpatient based care coordination, and proactive health and disease management efforts.
Develops and communicates outcomes and projected time frames for plan objectives to any audience.
Accountable to maximize strategic initiatives to achieve high level clinical integration and standardization of work processes, policies/procedures, administrative processes, and other necessary efforts to maximize efficiency and effectiveness of the program.
Demonstrate high level skill in navigating successful relationships with third party payers representing patient and the health system.
Communicate and gather feedback from interested stakeholders regarding plans and direction for the case management function.
Organize information from multiple sources into meaningful reports and communications.
Serve as a liaison and contact person for concerns and questions relative to case management, care coordination, social work services and utilization management.
Establish productive steering/advisory mechanisms where indicated to support collaboration and integration efforts.
Leadership of the Case Management Function
Identifies required resources and develops and effectively administers budgets in assigned areas.
Develop and monitor lead and lag measures which serve to assess the effectiveness of case management processes.
Assure case management workforce demonstrates consistent knowledge and skill requirements for effective case management practice and develops methods to assess initial and assure ongoing competency.
Identify and recommend appropriate staffing levels to achieve the goals of case management efficiently provided.
Monitor and align departmental processes to support reduction in exposure to payment denials, quality or patient safety issues or other untoward organizational outcomes.
Develop effective collaborative relationships with other organizational leaders.
Regulatory Compliance and Performance Improvement
Prepare/ensure that appropriate records, reports and statistical studies are completed for compliance documentation regarding Beacon Health System standards and external regulatory agency requirements.
Assure effective functioning of Utilization Review Committees of each acute care hospital.
Serve as a Hospital and Health System resource regarding revenue cycle, transition planning and social work services topics and identifies, leads and participates in performance improvement activities as needed.
Work cooperatively with the Denials and Appeals and Managed Care department to analyze contract and payment activity and improve performance of internal work processes to avoid payment risk.
Assure effective functioning of all delegated leaders of various functions in the case management enterprise continuum.
Conducts performance reviews in accordance with established policies and procedures.
Work collaboratively with physician liaison to support medical staff in case management processes including designing effective programs for case reviews, third party provider interactions, medical staff continuous learning to maximize working knowledge of payer practices, medical necessity requirements and documentation.
Through regular effective communication with associates in the case management continuum assures engagement/alignment with program goals and objectives.
Foster effective program development and process improvement through efforts to involve associates at all levels in design and performance improvement efforts.
Contribution to Effectiveness of Program and Health System
Maintains personal competence in Case Management processes and remains continuously current re: issues and trends in the industry.
Completing other job-related assignments and special projects as directed.
Manages the population health business risk of the Health System
Ability to influence behavior and drive change with the population managed in the ACO, and value based contracts
Experience in developing relationships with Health plans and payors
Development of metrics and dashboards to track progress
Directs the establishment and enforcement of standardized processes
Attend and participate in department meetings and is accountable for all information shared.
Complete mandatory education, annual competencies and department specific education within established timeframes.
Complete annual employee health requirements within established timeframes.
Maintains license/certification, registration in good standing throughout fiscal year.
Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
Adheres to regulatory agency requirements, survey process and compliance.
Complies with established organization and department policies.