Director, Case Management
The Director of Case Management will provide leadership to develop a case management model based upon a program goal of physician centered, seamless delivery of care across the continuum and will support Disease Management and Quality Improvement initiatives. The Director will identify Case Management needs and initiate a plan to develop, manage, and evaluate integrate patient delivery systems.
The Director of Case Management will function, as a consultant in the management of care needs for all patients and will follow patients across the continuum and will participate in the systematic collection and evaluation of quality and variance data as well as utilization management data.
The Director of Case Management will work closely with physician groups, the director of Managed Care and third party payers in all aspects of case management including utilization review, discharge plan, social services, quality resource management. Case Management issues will be addressed through demonstrated critical thinking and creative problem solving by collaborating with members of interdisciplinary team, as identified by the director. The Director will assist in facilitating the achievement of optimal outcomes in a cost-effective manner.
Reports to the Sr. VP of Operations
1. Masters Degree in nursing, or health care administration, or business administration.
2. At least 3 years of case management and managed care experience.
3. Current Massachusetts license in nursing.
4. Strong understanding of managed care
5. Sound clinical judgment
7. Excellent function development and management skills
8. Excellent communication and negotiation skills
9. Relationship manager - providers, committees, payers
10. Strong organizational skills
1. Develops integrated case management program:
A. Evaluates current case management services and identifies needs and opportunities for quality improvements and increased PCP focus.
B. Develops policies and procedures to support integration and effectiveness of case management efforts.
C. Leads efforts to develop comprehensive large case management program.
D. Works closely with PCP'S and serves as intermediary with payers.
E. Assesses provider performance on claims reports. Oversees the development of reports to interpret the data.
F. Provides guidance to providers regarding utilization review process, results interpretation and identifying needs.
G. Participates in the evaluation of community resources utilization.
H. Maintain hospital’s relationship with area Skilled Facilities and other vendors as necessary.
I. Identifies opportunities for collaboration and coordination across system.
J. Negotiate contracts with facilities and vendors as necessary for patient continuum of care.
K. Function as a leader in the Utilization Review Committee under direction of the physician chair.
2. Ensures information systems are in place to support case management:
A. Coordinates evaluation of software packages and makes recommendations.
B. Ensures appropriate interface with Meditech system.
C. Maintain appropriate educational training for computer systems with staff of Case Management Department.
D. Work with liaison in IS department to develop department specific reports for daily workflow and data collection.
3. Coordinates disease management efforts:
A. Ensures that appropriate protocols are being developed to support disease management programs.
B. Develops disease management committees.
C. Participates in interdisciplinary teams to institute system-wide supports for disease management initiatives.
D. Work in collaboration with insurance carriers to promote Disease Management programs to medical staff for appropriate referrals.
4. Provides educational programs regarding managed care programs:
A. Develops and delivers case management principles to physicians, staff and others.
B. Work with physician leadership to educate physician staff on an ongoing basis about changes to managed care.
5. Develops case management organization:
A. Develops case management organization and staffing plan.
B. Participates in defining new positions and in hiring incumbents.
C. Oversees the work of case management staff and providers for the ongoing development of performance.
D. Develops and manages case management budget.
E. Develops a database, which quantifies and tracks ongoing case management initiatives resulting from third party payment issues.
F. Act as a liaison for Insurance case managers and other non-hospital staff case managers overseeing their role within the hospital.
G. Work with department leaders to increase quality of patient care.
6. Case Management Duties:
A. Act as a resource for all Case Management staff.
B. Carry an active caseload as necessary.
C. Maintaining skills of assessment, planning, implementation, coordination, monitoring and evaluation for each case involved with.
D. Educate nursing staff and ancillary departments about multidisciplinary care rounds.
E. Have case management staff actively participates in hospital orientation.
F. Act as a patient advocate when necessary to achieve outcomes towards patient goal.
G. Work with families to address care needs and other issues for the patient.
7. Performs related and unrelated responsibilities, as needed.