|ESSENTIAL JOB FUNCTIONS: |
Responsible for the recruitment, selection, orientation and training of staff. Responsible for the development and communication of staff performance plans and writes and conducts annual performance appraisals. Assigns and monitors work, measures performance and provides opportunities for staff development. Implements corrective measures and discipline as necessary.
Works collaboratively with the Director of Clinical Services to define and measure goals for organizational/departmental performance and determine the tasks and resources needed to attain them.
Participates in the development, implementation, and evaluation of Care Management Programs as part of the annual strategic initiatives and reporting. Manages daily activities of Care Management clinical staff, individually and as a team to ensure the following objectives are met:
Develops and implements work plan(s) and Individual Care Plan(s), ensures continued progress of goals and objectives
• Monitors clinical interventions for relevancy, timeliness, and effectiveness and assures compliance with regulatory bodies
• Audits authorizations
• Monitors clinical documentation for appropriate and timely tracking, objective, concise and legally defensible documentation charting, and reporting in software
• Ensures teamwork on standards, procedures, and process implementation
• Provides clinical support and direction to staff for inpatient reviews, handling ambulatory cases, or reviewing referrals or authorizations.
• Collaborates with the Director of Clinical Services to create and refine documentation, including written program description(s), standards and procedures, guidelines, program evaluation, workflows and other relevant records. Responsible for the timely revisions, maintenance, and storage of such documentation.
• Manages the Supervisors in Care Management. Develops and implements a culture of continuous process improvement in order to improve our accuracy, documentation and turn-around-times for all referrals and authorizations. Assures compliance with all contractual and regulatory agencies in regards to Care Management and UM processes.
• Ensures activities and documentation comply with industry and regulatory standards, and national based criteria. Reviews and reports to the various health plans, or other stakeholders as required.
• Collaborates with the Director of Clinical Services and Medical Directors on program objectives and strategic direction.
• Serves as a point of contact for key external stakeholders, such as health plans, ancillary providers and vendors for IP care coordination and program development.
• Audits IP Care Management programs as it relates to clinical documentation. • Assures compliance with all payer contracts and federal, state, and county regulations and mandates for utilization review
• Responsible for contributing to the development and distribution of annual/bi-annual reports (program descriptions, work plan, program evaluation, and progress reports) as required by Industry Collaborative Effort, Health plans, or regulatory bodies.
• Works collaboratively with the leadership team in Medical Services to continue program awareness, and to ensure appropriate referrals to programs.
• Serves as a Care Management “content resource” to BTMG. Conducts necessary research on relevant and current issues in the industry. Provides education to Care Management, Quality Management and Utilization management industry wide activities. Prepares ad hoc reports as necessary.
• Represents Medical Services on select interdepartmental committees and workgroups. Serves as Project or Team Lead on behalf of the department as assigned by Director of Clinical Services. • May represent BTMG on select external coalitions, task forces, regulatory agency work groups/committees, etc. ensuring Brown & Toland interests are appropriately conveyed.
EDUCATION AND/OR TRAINING:
• Bachelor Degree in Nursing is required. • Must have an active California RN License • Master’s Degree preferred in nursing, public health or other health related field preferred. • Advanced practice certification, ARNP or certifications applicable to position (CCM, CDMS, CRC, CRRN, CHON, and CPUR) is nice to have. • Working knowledge of utilization management, reimbursement, medical necessity criteria including InterQual. • Must have knowledge of managed care concepts, Medicare/Medi-Cal Guidelines.
SKILLS AND ABILITIES:
• Ability to establish a compassionate environment by engaging and calmly discussing difficult patient issues • Must be willing to travel to various locations • Strong leadership, supervision interpersonal and organizational skills • Must have strong communication skills, both oral and written • Excellent customer services skills • Strong problem-solving skills and flexibility • Demonstrated ability to work independently and self-directed • Ability to plan, organize, prioritize, evaluate and document • Excellent presentation skills • Strong computer skills using MS applications in Outlook, Word, Excel, Access, and PowerPoint. Ability to VPN to remotely access systems and ability to navigate software systems for electronic documentation • Knowledge of State and Federal regulations, HMO, PPO and Utilization processes • Knowledge of Discharge Planning and Case Management • Knowledge of principles and practices of Utilization and Quality Management • Knowledge of CPT, IDC-9 and 10 Coding
• Experience in a managed care (HMO or IPA), clinical or public health setting supervising licensed and unlicensed staff • Minimum of three years Utilization Management experience • Minimum of two years’ experience managing clinical and/or non-clinical Case/Care Management staff required
Candidates should be local to the San Francisco Bay Area. For immediate consideration, please contact Jamie Kirchenwitz at email@example.com