Manager Clinical Specialty Pharmacy
At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion, and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.
We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.
In support of this, we commit ourselves to the following values:
If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.
Position Summary: The RN Care Coordinator is responsible for overseeing the appropriateness of care provided to members of health plans contracted by the hospital and being held accountable for appropriate financial and clinical outcomes of these patients. The RN Care Coordinator will be assigned to selected areas of the Hospital on a rotating basis to perform utilization reviews and other UM activities, as needed based upon department staffing and coverage. The RN CC will support and coordinate the activities of the Social Workers assigned to the unit. As this is an evolving position, duties and responsibilities may vary based on specific assignments.
Accountability: Manager/Director of Care Coordination
- Recent experience in acute care setting involved with clinical activities and/or a managed care environment working in case management
- Recent experience in a case management role or related role
- Excellent computer skills including managing work against performance metrics and reporting on key indicators important to the department
Education and Competencies:
- Bachelor’s in Nursing required and Masters preferred ( Nursing Masters not required for this advanced degree)
- InterQual experience
- Strong computer skills with knowledge and proficiency with Microsoft Word, Excel and PowerPoint
- Strong data analytic skills to prepare and monitor management reports regarding the performance of the areas assigned and the Department
- Demonstrated experience with managing against clinical and financial indicators and performance goals
- Demonstrated skills in working collaboratively with physicians, managers and other team members
- Demonstrated skills in organizing and directing staff teams to complete assignments accurately and on time
- Exempt position
- Current licensure in Massachusetts as a Registered Nurse
- BLS certification required
- Case Management Certification preferred
- Evidence of continued professional development
Scope of Authority:
- Perform InterQual reviews on assigned patients and working with insurers to provide clinical information, answer questions, obtain insurance authorization for patients.
- Support Social Workers (SW) Care Coordinator on the floor who will be responsible for the development and execution of patient discharge plans.
- Help the SW Care Coordinators prioritize work and/or support clinically difficult discharge plans with the Social Workers.
- Prepare and review reports on the Department’s performance including but not limited to - LOS, clinical denials and appeal status, avoidable days, time of discharge, proper level of documentation.
- Work with Care Coordination Manager/Director to develop educational needs and identify strategies to accomplish objectives of the Department.
- Given this job position is a new position; additional tasks may be added as the position is further developed.
UM Reviews and Denial Support
- Perform Interqual Admission Assessments on all new admissions and forward the reviews to insurers. Answer questions from the insurers and continue to provide any additional clinical information they request. Timely reviews to be provided so payers have sufficient time to review case and respond quickly.
- Communicate in real time with physicians on any patients not meeting criteria and establish a course of action. Work collaboratively with the MDs to help them understand documentation issues or any leveling issues. Provide education to them regarding Inpatient vs. Observation criteria or daily care criteria.
- Obtain insurance authorization numbers for patients requiring inpatient, outpatient and/or post acute authorization prior to ordering and delivering services. Authorizations to be obtained in a timely manner to not delay discharge.
- Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
- Perform concurrent/daily InteQual reviews on assigned patients. Forward all reviews to insurers on a timely basis. Answer any questions from insurers. Perform concurrent denial management to resolve issues prior to discharge of patient
- Upon receipt of admitting or daily denials from insurers, review the case and provide the insurer with additional clinical information to reverse the denial.
- Maintain a complete clinical record and profile on a patient’s clinical conditions in Allscripts. Utilize the Allscripts tool appropriately so all fields are complete, all clinical information is fully recorded, all changes
- to a patient’s clinical condition is recorded, all interaction with insurers, RNs, MDs is documented, as appropriate.
- Copy the Allscripts clinical information and place in medial record, as appropriate.
- Task all worked denials for appeal to the Appeal Coordinator.
- Finalize authorization for stay for all covered days prior to case closure
- Rotate to other units of the Hospital including the ED as directed by the Care Coordinator Manager and the schedule for the Department. Rotate and cover weekends and holidays, as directed by the CC Manager/Director. For all areas of the Hospital, perform all the functions stated in job description.
Discharge Planning and Execution:
- Review initial Admission Assessments and proposed discharge plans performed by the Social Worker CC. Provide any feedback to Social Workers concerning the case. Identify the patients/discharges that may be complicated and review these discharges with the Social Worker. Provide any guidance as needed.
- Coordinate and monitor discharge planning activities for an assigned patient population and provide support to the Social Worker CC and administrative staff managing the discharge process.
- Work with the discharge team and the PCPs/Hospitalists on creating an individualize discharge plan for high-risk patients, as needed, to ensure appropriate level of services are scheduled for the patient.
- Educate PCP’s and clinical staffs on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives.
- Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health Agencies, physicians and other staff to insure all post-acute clinical information is provided. Information to be provided on a timely basis to not delay discharge.
- Obtain information from the CC Manager and CC Supervisor on Social Worker CC assignment and provide feedback, as needed, on SW assignments, priority of work and any follow-up issues.
- Communicate regularly with the CC Supervisor on any challenges with Social Worker CC performance and SW schedules.
- Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate.
- Provide patient education and family teaching, on an as needed basis.
- Act as an advocate for the patient.
- Promote nursing care within legal, ethical and professional standards.
- Facilitate/coordinate multidisciplinary care patient care rounds on medical/surgical units, as needed.
- Attend UMCM meetings, as appropriate
- Maintain daily tracking tools, as needed, to help the Department collect data and track performance. Tracking tools to be developed by the Department. Examples of indicators to be monitored include ( but not limited to):
- LOS reports-
- Identify long lengths of stay – report on reason for outliers
- Identify short lengths of stay –under 24 and 48 hours and investigate possible observation, documentation in place for level of care
- Monitor number of avoidable days
- LOS reports-
- Denial reports
- Review level of denial
- Review reason for denials
- Review denial back-logs
- Identify opportunities for lowering rates
- Identify MD teaching opportunities to lower denial rate
- Prepare information required to respond to denial/appeal
- Denial reports
- Inpatient to Observation conversion reports
- Identify trends in inpatient admits being converted to Observation
- Review dates of conversion – to ensure conversion happening prior to discharge
- Review opportunities for MD education- ED MD and admitting MD/Hospitalists
- Inpatient to Observation conversion reports
- Review with the CC Manager management reports that provide Department performance metrics of Department and personal performance. Performance metrics to include but not limited to: clinical denials, clinical denial backlog, outcome of clinical denials, timely admitting and daily reviews, full use of Allscripts, full documentation of cases in Allscripts,etc.
- Review own personal performance and provide feedback in writing on how to improve performance on a routine basis.
- Review use of Dove Tail and other Steward services, as appropriate and work to increase referrals to these services, as appropriate for each case.
- Support the Care Coordination Manager/Director in maintaining the financial and clinical outcomes of the Care Coordination Department.
- Support the Steward physician network by coordinating with the Steward ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community/ambulatory care coordinators are put in place.
- Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
- Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
- Identify service needs, systems issues and opportunities for improvement for the Department
- Review out-of-network referrals and scheduled procedures in order to manage the financial and utilization management of managed care contracts. Collaborate with the PCP and/or specialist to determine the possibility of redirecting care to/within the Steward network.
- Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
- Report deviations in quality care to the Manager/Director of Care Coordination.
- Assist with the development of clinical guidelines, as needed.
- Maintain current knowledge of regulatory requirements including changes to payer requirements, reporting and regulatory requirements.
- Demonstrate effective leadership skill
- Attend weekly Care Coordination meetings
- Complete all paper work required for regulations.
- Complete all Code 44 paperwork.
- RN Care Coordinator will be evaluated based upon clinical and financial criteria where they influence the outcome. Some of these criteria include –but not limited to:
- Clinical denials
- Clinical denial back-log
- Outcome of clinical denials.
- Lengths of stay
- Timely patient discharges – goal is 11:00am for patient discharge
- Full use of Allscripts, Meditech and InteQual.
- Full clinical reviews available in Allscipts
- Timely submission of clinical reviews to insurer
- Timely admission and concurrent reviews available for insurer
- Inter-rater reliability scores- performed routinely throughout the year.
- Demonstrated collaboration with Social Worker CC, CC Supervisor, CC Manager, physicians, residents and RNs on floor. This evaluation will be measured with feedback for other members of the care team
- Information for staff evaluations will be collected by Department and will be made available for performance reviews. Selected data will be provided by the RN Care Coordinator. Other data will be provided by CC Manager, Social Workers and the CC Reviewer.
Important COVID message
This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.
Please note, St. Elizabeth’s Medical Center is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.