Under administrative direction, manages,
coordinates, and evaluates the delivery of continuity of care and utilization
of services in an inpatient, acute care setting as required under federal and state
regulation and performs other work as required.
CLASS CHARACTERISTICS
Under direction of the Chief
Nursing Officer or equivalent executive leadership, this single-incumbent
classification provides administrative and clinical strategic direction, oversight,
and leadership to a unit of professional and support staff involved in
providing case management/continuum of care services. This at-will
classification does not provide direct patient care and is exempt from the San
Joaquin County Civil Service System.
TYPICAL DUTIES
This specification is a general guideline for this classification. The statements below are not restrictive, and the responsibilities and duties assigned to a position in this class may expand beyond those identified in the specification.
Plans, organizes, and directs patient care coordination activities in a hospital or other acute care setting for a select group of patients with complex diagnoses and health care needs.
Directs development and implementation of facility-wide care transitions, discharge planning and utilization standards to ensure coordinated plans of treatment, customer focused delivery of services, and cost-effective utilization of necessary services.
Establishes and implements a Case Management program in compliance with federal, state, county, and contracted agencies’ regulatory mandate and law. Oversees the development of department standards as identified by regulatory agencies, including The Joint Commission. Maintains a state of continuous regulatory readiness.
Interprets federal and state regulations, contracts and agreements related to utilization review and inpatient reimbursement.
Maintains oversight and monitors effectiveness of the concurrent and retrospective inpatient reviews and appeal process, discharge planning and transition of care services; conducts quality of work and compliance audits of casework.
Coordinates with the Physician Chairman of the Utilization Review Committee to meet the Joint Commission requirements; educates physicians and hospital staff.
Collaborates and develops effective working relationships with physicians and multidisciplinary teams with hospital and community entities to ensure timely and coordinated discharge planning for patients; negotiates effective contracts with external providers, community partners, and other contractors for service.
Trains and develops the Case Management staff to accomplish department goals and objectives; ensures efficient use of resources, develops processes to screen, interview, hire, train, and maintain the competency of subordinate staff.
Provides oversight and monitoring of the assigned budget area, analyzes data, and performs cost analysis as needed.
Identifies and implements resource reduction strategies consistent with facility strategic plan with a focus on quality outcomes, reduction of length of stay, medical necessity, and appropriate levels of care.
Participates in leadership activities to drive quality, performance improvement, consistency of operations and cost-efficiency.
Works towards reducing administrative, avoidable and denied days; provides a secondary review of cases that do not meet the established criteria.
Provides information regarding changes in MediCal and Medicare regulations and documentation issues to physicians, nurses, and others as needed.
Establishes, prioritizes, and meets utilization goals; monitors utilization indicators; identifies and escalates issues; and initiates and evaluates action plans for achieving the areas goals/targets.
MINIMUM QUALIFICATIONS
DESIRABLE QUALIFICATIONS
Education: Possession of a Bachelor’s Degree in Nursing, Health Science, Business Administration, or other closely related field.
Experience: Four years of progressively responsible registered nurse case management experience in an acute care hospital, including two years of case management supervisory or management experience in an acute care setting.
Substitution: A Master’s Degree in Nursing, Health Care Administration, Business Administration, or other closely related field may be substituted for one year of the required non- management experience.
REQUIRED QUALIFICATIONS
License and Certification: Current registration as a nurse in the State of California and current certification in Case Management.
KNOWLEDGE
Principles and practices of supervision, staff development, organization, administration, fiscal, and program management; budget preparation and monitoring; principles and practices of nursing and patient care services for care management, discharge planning, and utilization management in an acute health care setting; federal and state health care laws and regulations common to the operation of hospitals in California; financial processes of various private and public funding sources; regulations of intermediary agencies pertaining to hospital stay coverage (e.g. Medicare/Medi-Cal); principles and applications of hospital information systems as they relate to care management and utilization review; criteria for level of care and current standards in medical and nursing practice; professional nursing theory and techniques; available alternative patient services and treatments; English usage, style, grammar, punctuation, and spelling; and common computer systems and applications.
ABILITY
Exercise analytical and critical
thinking skills; make sound managerial decisions; provide effective and
efficient management advice in a high paced environment; serve as a resource to
physicians, nurses, and care management staff; keep abreast of, understand,
interpret, apply, and implement healthcare laws, rules, regulations, and
procedures; evaluate data and statistics and prepare reports; select, train,
supervise, develop, evaluate, discipline, and motivate staff; work effectively
as a member of a management team in a large health care organization; establish
and maintain effective working relationships with those contacted in the course
of work, at all levels, including colleagues, the public, and representatives
of other agencies; communicate effectively, both orally and in writing, with
people of diverse backgrounds and cultures.
PHYSICAL/MENTAL REQUIREMENTS
Mobility-Frequent operation of data entry device; occasional standing and walking; frequent driving and sitting may be required; Lifting-occasional lifting 5 to 10 pounds; Vision-frequent hand-eye coordination, depth perception, reading and close-up work; Dexterity-normal dexterity with occasional writing; Hearing/Talking-constant hearing and talking on the telephone/radio and in person; Emotional/Psychological-constant decision making with frequent concentration required; Special Requirements-may occasionally work weekends/nights; may be required to travel; Environmental Conditions-occasional exposure to noise.
San Joaquin County complies with the Americans with Disabilities Act (ADA) and, upon request, will consider reasonable accommodations to enable individuals with disabilities to perform essential job functions.
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