The System Director of Case Management manages the functions of Care Coordination, Social Work, Discharge Planning, and Utilization Management, including supervision of Case Managers, Social Workers, and administrative support staff. The Director collaborates with hospital and department leaders to ensure efficient and effective use of clinical resources and reimbursement by third party payers. The Director oversees the processes that ensure reimbursement by third party payers including admission reviews, concurrent reviews, and management of denials and appeals. The Director provides guidance to the Social Workers and Case Managers to maximize reimbursement by third party payers and ensure continuity of care within St. Lawrence Health System and it’s entities whenever possible.
The Director ensures the discharge planning process is responsive to patients’ needs. The Director monitors the effectiveness of discharge planning and tracks readmissions to identify preventable readmissions and problems in the discharge planning process.
The Director serves as the primary point of contact with community post-acute providers.
STATUS: Full Time
LOCATION: Canton Potsdam Hospital
SCHEDULE: 8 hours variable
**$10,000 sign-on bonus available for qualifying, successful candidate!
- Bachelor’s degree in nursing required; master’s degree in health-related field preferred
- Licensed Registered Nurse
- Case Management Certification preferred; obtains certification within two (2) years of employment
- Minimum of ten (10) years management experience in related position required with demonstrated progressive responsibility
Knowledge / Skills / Abilities/ Essential Job Functions:
- Excellent verbal and written communication
- Excellent interpersonal skills
- High degree of initiative and independent decision-making
- Excellent critical thinking
- Ability to establish and sustain a positive impact on all levels of the organization
- Ability to demonstrate high level of commitment to the organization
- Excellent relationship-building skills
- Exceptional customer service and organizational skills
- Understanding of health care continuum and care coordination competencies
- Knowledge of CMS Condition of Participation regulations and The Joint Commission standards
- Knowledge and understanding of computer systems and software applications
- Oversees and monitors operational performance of Case Management
- Collaborates with the Chair, Utilization Management Committee and hospital leadership to set annual priorities and goals for the department.
- Establishes and standardizes defined policies, procedures, and processes to optimize efficiency and maximize productivity.
- Manages Case Managers, Social Workers, and administrative support staff.
- Monitors daily volumes and complexities of caseloads to assure effective workloads.
- Collaborates with the department’s Physician Advisors regarding complex cases, third party payer issues, and interaction with Case Managers and Social Workers.
- Uses data to establish a Case Management dashboard, monitor utilization trends, and identify performance improvement opportunities.
- Presents data and trends to the Utilization Management Committee to monitor performance, identify performance improvement opportunities, and gain support for implementation of strategies to improve clinical management.
- Leads Case Management performance improvement initiatives.
- Collaborates with all disciplines and departments to implement process improvements.
- Oversees department operating and capital budget
- Utilizes national benchmarks to make staffing recommendations
- Monitors staff productivity on a bi-weekly basis
- Prepares and monitors operating and capital budgets
- Assures Case Manager and Social Worker competency
- Mentors and acts as a resource for staff
- Evaluates Case Managers’ and Social Workers’ performance
- Collaborates with Human Resources, Nurse Managers and Physician Advisors to recruit and select new staff
- Plans orientation and continuing education of staff
- Ensures that all staff understand and integrate caring service standards into their interaction with patients, families, and other employees
- Audits Case Managers’ competency for appropriate application of clinical criterion
- Audits Case Managers’ and Social Workers’ discharge plans for appropriateness, quality and effectiveness
- Monitors patient satisfaction with care coordination and discharge planning services
- Develops a professional development plan for each Case Manager and Social Worker
Revenue Cycle Operations
- Ensures appropriate certification and reimbursement by third party payers, including monitoring departmental procedures and interface with third party payers
- Collaborates with Patient Access Services, Patient Financial Services, and Health Information Management departments to ensure timely and accurate certification and reimbursement by third party payers; maintains ongoing open communication to address identified problems.
- Establishes working relationship with third party payer representatives
- Oversees third party payer denials and appeals processes
- Collaborates and communicates with Managed Care and Revenue Cycle Management departments to ensure problems and barriers with third party payers are addressed in an effective, timely manner
- Recommends revisions to managed care contracts when such needs are identified
- Identifies and evaluates changes in third party payer policies and procedures; communicates changes to hospital leadership, Case Managers, Social Workers, Nursing Leadership and Medical Staff
- Provides reports of third-party payer denial activity and internally identified avoidable days to Utilization Management Committee; analyzes trends and identifies improvement opportunities.
- Acts as subject matter expert for Case Management
- Monitors current CMS Condition of Participation regulations, State Department of Health regulations, and The Joint Commission standards affecting departmental practices
- Develops and implements policies and procedures to ensure regulatory compliance
- Provides educational updates for Case Managers, Social Workers, Physician Advisors, and Medical Staff
- Collaborates with all disciplines and departments to develop and implement new policies and procedures to ensure compliance with new regulatory and operational requirements
- Audits staff and Physician Advisor compliance with regulations and standards
- Establishes working relationships with community post-acute providers including skilled nursing facilities, rehabilitation hospitals, specialized post-acute services, home health care agencies, durable medical equipment providers, and hospices
- Evaluates the care capabilities of each provider
- Ensures the accuracy and integrity of referral processes, transitions of care, and data profiles of post-acute providers
- Oversees the development of a post-acute provider performance dashboard and quality metric reporting
- Monitors the performance and quality of post-acute providers; initiates discussion with post-acute providers to resolve problems, prevent readmissions, and improve transition of care
- Ensures discharge plans are responsive to the patient’s post-discharge needs
- Collaborates with physicians, all disciplines, and departments to ensure an effective discharge planning process.
- Implements a system for ongoing reassessment of the discharge planning process that includes a review of current discharge plans, audit of closed medical records, and tracking of readmission rates
- Reviews current readmission cases and closed medical records with Case Managers to determine if the readmission was potentially due to problems in discharge planning or implementation of the discharge plan
- Monitors patient satisfaction with the discharge planning process
- Solicits feedback from post-acute providers and community physicians about the effectiveness of the hospital’s discharge planning process
- Reports the results of the evaluation of discharge plans to the Utilization Management Committee; makes recommendations for follow-up action and changes
- Tracks readmission rates and investigates readmission trends to identify areas for improvement
- Reports readmission rates, trends and improvement activities to the Utilization Management Committee; makes recommendations for further follow-up action and changes
- Collaborates with hospital, medical, nursing and other department leadership to identify and implement strategies to reduce preventable readmissions and improve the effectiveness of discharge planning
- Assists in developing innovative care management programs across the system
- Collaborates with the hospital’s leadership team to develop and implement future transition of care and case management programs
- Works with hospital leadership to develop and implement transitional care strategies to enhance patient self-management of chronic illness
- Works with service line leaders, medical homes, and the preferred home care companies to develop and implement disease management programs that enhance patient self-management of chronic illness and prevent readmissions