Manager, Care Management
Alameda Health System
 Oakland, CA

SUMMARY:# Responsible for the day to day operations of facility wide utilization, discharge planning and care coordination. DUTIES # ESSENTIAL JOB FUNCTIONS:# NOTE: The following are the duties performed by employees in this classification.# However, employees may perform other related duties at an equivalent level.# Not all duties listed are necessarily performed by each individual in the classification. 1. Assists Director in Establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies. 2. Conducts and records periodic staff meetings, to inform staff of changes in policies and procedures. 3. Conducts interdepartmental team conferences for identifying aberrant utilization; establishes a method of tracking variances based on critical timelines. 4. Develops and provides statistical UM information and reports to appropriate committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality of patient care. 5. Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects. 6. In conjunction with VP and Director, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum. 7. Manages and assumes responsibility for day to day operations of utilization management, care coordination and discharge planning activities. 8. Manages process of pre-admission review of questionable admissions as referred by Admitting, Emergency Room and medical staff and offers workable solutions. 9. Oversees submission of any audits, including but not limited to MediCal, Medicare and internal compliance studies. 10. Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payors through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding care management issues. 11. Perform all other duties as assigned. 12. Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability). 13. Prepares cost analysis reports and other data needed for the preparation of the departmental budget. 14. Provides in house educational programs as needed for both staff and physicians. 15. Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff. 16. Responsible to purchase, educate, and record education to new equipment and/or techniques. 17. Reviews cases regularly with staff; acts as clinical consultant regarding care management issues; guides clinical staff with review of assessments and care plans, evaluates utilization reviews or documentation. 18. Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession. 19. Supervises technical procedures and performs procedures as needed. MINIMUM QUALIFICATIONS: Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM. Preferred Education: Master#s in Nursing or Masters in Social Work or related field. Required Experience: Five years of clinical nursing experience in a directly related setting (e.g., acute care, skilled nursing, etc.); three years of case management experience; two years of experience in a supervisory or lead role. Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California or licensed in Clinical Social Work in California, Active BLS - Basic Life Support Certification issued by the American Heart Association. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training.

SUMMARY: Responsible for the day to day operations of facility wide utilization, discharge planning and care coordination.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

  • Assists Director in Establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies.
  • Conducts and records periodic staff meetings, to inform staff of changes in policies and procedures.
  • Conducts interdepartmental team conferences for identifying aberrant utilization; establishes a method of tracking variances based on critical timelines.
  • Develops and provides statistical UM information and reports to appropriate committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality of patient care.
  • Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects.
  • In conjunction with VP and Director, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum.
  • Manages and assumes responsibility for day to day operations of utilization management, care coordination and discharge planning activities.
  • Manages process of pre-admission review of questionable admissions as referred by Admitting, Emergency Room and medical staff and offers workable solutions.
  • Oversees submission of any audits, including but not limited to MediCal, Medicare and internal compliance studies.
  • Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payors through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding care management issues.
  • Perform all other duties as assigned.
  • Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).
  • Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
  • Provides in house educational programs as needed for both staff and physicians.
  • Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff.
  • Responsible to purchase, educate, and record education to new equipment and/or techniques.
  • Reviews cases regularly with staff; acts as clinical consultant regarding care management issues; guides clinical staff with review of assessments and care plans, evaluates utilization reviews or documentation.
  • Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
  • Supervises technical procedures and performs procedures as needed.

MINIMUM QUALIFICATIONS:

Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM.

Preferred Education: Master's in Nursing or Masters in Social Work or related field.

Required Experience: Five years of clinical nursing experience in a directly related setting (e.g., acute care, skilled nursing, etc.); three years of case management experience; two years of experience in a supervisory or lead role.

Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California or licensed in Clinical Social Work in California, Active BLS - Basic Life Support Certification issued by the American Heart Association. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training.