- Evaluates, develops, implements and monitors utilization and case management and activities to promote quality and cost effective results.
- Collaborates with Social Work, Q.I. Nursing, Fiscal, Managed Care and other clinical departments as well as physicians, hospital administration, community agencies, and third party payers with an emphasis toward providing excellent patient care across the care continuum within a fiscally responsible framework.
Fiscal Responsibilities – reporting to Chief Financial Officer
- Directs member’s need for case management services, including verifying eligibility, benefit and insurance limitations, medical necessity and appropriateness of referral
- Reviews case management referrals by communication directly with physicians, HMO’s Medical Director, hospital staff and other appropriate ancillary providers on a regular basis
- Assesses quality of contracted vendors including quality outcomes, patient and physician satisfaction, cost and service levels
- Supervises the tracking of all referral and DME services
- Attends leadership meetings, participates in committees, identified and manages department priorities, plans budget and reviews staff
Clinical Responsibilities – reporting to Chief Medical Officer
- Responsible for supervising and/or performing case management, utilization review, quality assurance, and discharge planning
- Responsible for assisting CM’s in the assessment, identification, and awareness of services available to patients and families at the time of discharge
- Responsible for assisting CM’s in performing admission and concurrent review, and retro-review of all inpatients conforming to CMS requirements
- Coordinates Issuance of non coverage letters by CM’s at time of discharge when applicable
- Performing surveillance and data collection as directed for trend recognition and development of effective action plans
- Maintains compliance with state and federal guidelines as well as Joint Commission and CMS CoP standards
- Facilitates the Provision of information by CM’s in response to payer queries
- Participates in Continuing Education and other appropriate learning to maintain professional growth
- Utilizes Interqual criteria and standards for concurrent review requirements in supervising CM’s
- Prepares and distributes 3 day LOS reports daily to SLT
- Daily participation in morning rounds with house staff, CM’s and hospitalists in conjunction with the CMO
- Analyzes and presents clinical and utilization data to physician groups
- Educates clinical staff on alternative to acute care including new technology/alternatives for high tech home health, extended care and disease management initiatives.
- Supervises staff and provide direct services to inpatient units
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
1. Commits to recognize and respect cultural diversity for all customers (internal and external).
2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
- Performs other duties as assigned