This position is responsible for leading, supervising, managing, and coordinating the Case Management and Utilization Review departments. Directs both programs and is fully accountable for monitoring program activities, including compliance, planning, implementing, and evaluating program development to ensure clinical and financial activities promote the continuum of care and the appropriate use of clinical resources.
- Supervises the Case Management and Utilization Review staff, including hiring, training, assigning work, counseling, performance evaluation and other personnel/disciplinary actions. Monitors time and attendance for staff; approves leave and overtime hours. Monitors productivity and quality of work performed by all staff. Identifies and implements staffing changes which will measurably increase productivity of department operations.
- Manages the case management and utilization review model to ensure patient care delivery is performed in collaboration and coordination with the organization’s resources and multidisciplinary health care team(s) (i.e. Nurses, Physicians, Clinical Case Management, Patient Benefit Coordinators, Patient Registrars, Purchased and Referred Care).
- Administers case management and utilization review programs and service in accordance with Federal laws, regulations, accreditation requirements, policies, procedures, and guidelines; and bases recommends to managers and professional health care providers on costs and benefits of proposed case management actions.
- Ensures Case Management staff develop a care delivery system/service plan based upon the patient’s identified needs, available providers, financial resources, family, caretaker(s), and multidisciplinary health care team, which may include other Navajo Area Service areas and/ or other non TCRHCC providers as appropriate.
- Works as a liaison to promote the healthcare of patients and improving care coordination between Case Management, inter-departmental staff, and outside providers. Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Case Management Division.
- Responsible for initiation, preparation, and oversight of all contracted services for the case management program and represents TCRHCC at inter-agency meetings that may impact case management policy or result in memorandums of agreement to support program initiatives.
- Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
- Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care. Responsible for review, research, and decision of first level appeal process.
- Leads education activities to enhance the quality and completeness of clinical documentation, and patient care coordination. Makes certain training/continuing education is available for staff as appropriate either on-site or external training to improve skills in data entry of all Case Management Services referrals.
- Ensures Utilization Review staff conducts timely follow-up reviews of clinical documentation from pre-admission to post-discharge, continued stay, cost containment and discharge planning, and issues are discussed and clarified with the physician, and recorded in the patient’s chart.
- Ensures Utilization Review staff collaborates with the House Supervisor and the accepting physician regarding the appropriateness of the transfer of patients from discharging outside facilities to TCRHCC or return back to TCRHCC.
- Educates and oversees the Utilization Review nurses in modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of services rendered to all patients with a DRG-based payer. Ensures timely submission of inpatients admissions for Third Party Payors (TPA).
- Identifies utilization trends such as avoidable days, hospital acquired conditions, and denials of authorization and report these trends to appropriate Senior Leaders, committees, and staff to promote education and change within the facility.
- Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
- Leads and facilitates the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.
- Completes all patient care documentation in the electronic health record entries accurately and in real-time.
- Participates in departmental workflow and or testing teams as related to electronic health record or other project initiatives
- Performs other assigned duties as needed.
Must be able to recognize limitations and as for advice as needed with difficult cases. Effective critical thinking skills and judgment is used in interpreting and applying guidelines. Must ensure clinical documentation and reported data is complete and accurate. Within established objectives/parameters independently reviews and revises methods, processes and procedures with professionals and other staff. Identifies and seeks innovative approaches to resolution of issues.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
The work involves prolonged periods of sitting in an office setting operating a personal computer, as well as movement throughout the hospital to obtain and review medical records, and to meet with providers and clinical staff. Distant travel may be required for on-going and advanced training. Occasional travel to the satellite health centers for on-site reviews.
The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, in order to resolve complications and controversial matters.
The Director directly affects the quality of health care, improved health outcomes, improved access and proper function provided within the facility. The incumbent is the expert with regards to technical aspects of his/her profession and is held responsible and accountable for medical necessity review, follow up, education, and improvements of TCRHCC health care documentation quality and alignment with ongoing changes regarding payment criteria for all third-party groups.
TCRHCC is located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position and applicants who are enrolled members of any other tribe who meet the necessary qualifications will be given secondary preference.
In performance of their respective tasks and duties, all employees at TCRHCC are expected to conform to the following:
- Adhere to all professional and ethical behavior standards of the healthcare industry.
- Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possess cultural awareness and sensitivity.
All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles may be grounds for immediate termination.
I have read the qualifications and requirements for the position of Director of Care Coordination. To the best of my knowledge, I believe I can perform these duties.
Master’s degree in Nursing or healthcare related field
A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Accessing community resources for patient referrals
- Knowledge of diagnosis related groups (DRG) and documentation requirements
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Reliable and dependable; reports to work as scheduled without excessive absences
- Ability to sense varying skill levels and direct instruction accordingly
- Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
- Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
Board Certification with the American Case Management Association (Certified Case Manager) or successful completion with in six (6) months of employment
Other Skills and Abilities:
Ability to speak Navajo