Director Care Management

Company :

Job Description : 

GENERAL OVERVIEW:

This job is responsible for care management staff and processes at the Hospital as well as assuring integration and standardization across Allegheny health Network. The incumbent establishes practices to assure all patients have appropriate access to the facility, and that their care is coordinated and transitioned safely and efficiently.  The incumbent is responsible for managing and enhancing relationships and services in the community (this includes homecare, long term care, skilled nursing facilities, adult homes, medical homes, clinic, shelters and centers for homeless and populations with limited resources).  Develops relationships with the payer community and identifies opportunities to collaborate in utilization management and discharge planning. Responsible for leading the organization to implement and sustain predictable plans for patients during the continuum of care from pre-admission to discharge.  Serves as expert in utilization review and management.  Supports the Utilization Management Committee according to the responsibilities outlined in the Utilization Management Plan. Collaborates with physician advisors to identify utilization trends.  Works closely with the CFO and revenue cycle team to understand trends and implement strategies to reduce denials.. Studies national and regional trends and adjusts the case management model to meet financial, regulatory and clinical quality goals for the Hospital and health system.  Develops, monitors, and reports metrics to demonstrate department effectiveness and value to the organization.

ESSENTIAL RESPONSIBILITIES:

• Studies, evaluates, selects and implements systems to facilitate entry of acute care patients to the appropriate facility.  Once implemented, evaluates effectiveness and leads improvement efforts system wide to provide an effective admission structure.
• Develops and implements strategies with internal and external providers to ensure we are able to place patients in the right level of care at the right time predictably.  Works closely with VP, Care Management to assure consistent practice across the health system..
• Serves as a resource and mentor to the Care Management director team.  Assumes responsibility for implementing new care management processes across the system in response to changes in external health care and payer environment. 
• Establishes and implements development plan for nursing departments to create a
• Studies and implements the case management model and structure to achieve sustaining appropriate length of stay, resource utilization, and clinical outcomes for patients over time.  Responsible for designing and implementing improvement strategies for the care model on an ongoing basis.
• Oversees all activities related to referral management.  Develops collaborative relationships with payers and maintains compliance with payer contracts for utilization management.
• Leads initiatives to design and implement strategies to manage appropriate admissions and lengths of stay during all phases of inpatient segment of the continuum of care.
• Acts as a resource and provides ongoing education for department staff as well as system care management leaders, and the organization regarding national and regional trends; adjusts case management model to meet financial, regulatory and clinical goals for AHN in collaboration with the VP Care Management.
• Develops annual budget for areas of responsibility and works with department leaders and staff to implement the budget. Assures measures for staying within budgetary parameters.  Works closely with hospital leadership to plan budgetary needs annually.
• Leads development and implementation of strategies related to management of longitudinal care for patients connecting the pre and post-acute care with the short term acute care setting.
• Works closely with hospital leadership to develop a 5 year plan for areas of responsibility including implementation plans, timeline projections, financial projections, etc.
• Plans and implements recruitment and retention strategies for areas of responsibility in collaboration with Executive Nursing and Human Resources.
• Builds and maintains strong working relationships with colleagues internally in order to achieve throughput, length of stay and clinical quality goals.
• Develops, monitors and reports metrics to monitor effectiveness of utilization management and discharge planning strategies and effectiveness of all areas of accountability.

QUALIFICATIONS:

Minimum

• Master’s Degree in Nursing or related health care field.
• Current PA Registered Nurse license.
• Ten (10) years of acute care case management experience required, preferably at a tertiary care center and/or health system.
• Five (5) years of progressive management experience.
• 3-5 Years of experience with regulations and health finance related to management of patient care.

Preferred

• Case Management certification.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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