Provides leadership and direction to implement the case management plan within the continuum consistent with Vail Health Hospitalâ™s mission, values, goals and objectives. Participates with leaders of the Hospital, medical staff, and clinical areas to achieve optimal clinical and financial outcomes. Coordinates the planning, implementation and evaluation of the activities and staff engaged in care management.
ESSENTIAL JOB FUNCTIONS:
1. Develop, implement and perform ongoing reviews of an inpatient care management integration system by:
a. Oversight of Medical necessity of admissions to the hospitals; duration of stays; professional services furnished; delivery of required communications with Medicare beneficiaries.
b. Serve as a liaison and contact person for concerns and questions relative to inpatient care coordination, social work services and utilization management/review.
2. Direct and coordinate the planning, implementation and evaluation of the activities and staff engaged in care management by:
a. Develop and monitor lead and lag measures which serve to assess the effectiveness of the utilization review and discharge management processes.
b. Identify and recommend appropriate staffing levels to achieve the goals of case management, utilization management and social work.
c. Establish methodology and processes for assessment staff skills. Recommend education and training needs of staff regarding care management concepts and providing for learning opportunities.
d. Provide staffing and training to fulfill obligations related to attain prompt appropriate admission review, discharge planning, and payor communication.
e. Conduct performance reviews in accordance with established policies and procedures.
3. Provide leadership and direction in the area of Utilization Management/Review, with support of Director of Quality to assure compliance with regulatory agencies and third party payors by:
a. Prepare appropriate records, reports and statistical studies for compliance with Vail Health Hospitalâ™s standards and external regulatory agency requirements.
b. Prepares and directs the Utilization Review Committee with support from Physician Advisor.
c. Develop necessary Utilization Management and Social Services policies and procedures.
4. Collaborate with Clinical Documentation Improvement Specialist to ensure that no services are denied for lack of clinical information.
5. Support case management staff to fully utilize Interqual Cerme platform with daily evaluation of patient status, length of stay and supporting documentation.
6. Comply with the organizationâ™s policies related to privacy and release of information. Must be HIPAA compliant.
7. Role models the principles of a Just Culture.
8. Performs other duties as assigned.
This description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum of five years of experience and three years management experience required. Three to Five years recent management experience in acute care hospital.
Ability to obtain and maintain a State of Colorado Registered Nurse or Licensed Practical Nurse License required.
Case Manager Certification.
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
Must have working knowledge of the English language, including reading, writing, and speaking English.
A Masterâ™s Degree in a clinical or business related field preferred.
Internal Number: 7824
About Vail Health
Vail Health, formerly Vail Valley Medical Center, is a nonprofit community health care system serving patients and guests from around the world. Locally operated and governed by a volunteer board of directors, Vail Health includes a 56-bed hospital, accredited by the Joint Commission. Our 24/7 emergency department in Vail is a Level III Trauma Center with a nearby helipad for necessary medical transports. Vail Health provides a wide array of services and access points including Beaver Creek Medical Center, urgent care clinics in Avon and Gypsum, our Edwards medical campus, Eagle Healthcare Center and a multispecialty clinic in Frisco. Howard Head Sports Medicine offers physical therapy services at 10 locations and works closely with our internationally renowned orthopaedic partners at The Steadman Clinic and Vail-Summit Orthopaedics. In addition, Vail Health's Shaw Cancer Center and Sonnenalp Breast Center are the region’s only fully accredited cancer treatment center and comprehensive breast center. The Vail Clinic, which was founded in 1965, officially became “Vail Valley Medical Center” in 1980, its first year as a full-service hospital. At that time, we had one primary locatio...n and 25 physicians. Today, Vail Health has locations in nine towns, nearly 1,000 employees, 260 physician partners and 85 volunteers. Vail Health is an equal-opportunity employer. The hospital is handicap accessible and adheres to the Americans with Disabilities Act. Smoking is prohibited in our facilities. This includes e-cigarettes.