Director of Case Management - Nexus Children's Hospital - Houston, TX

Description

Under the direct supervision of the CEO, the Director Case Management develops and supervises policies and programs to ensure the delivery of case management services meets all patient/family psychosocial needs as well as ensuring planning, implementation, and evaluation of care for patients across the health care episode.  Supervises the management of patient and organization financial/medical resources to maximize recovery and meet all regulatory requirements.

Job Specific Responsibilities:

  • Oversees the Case Management Department and provides directs supervision to all department personnel
  • Ensures compliance with all PHI and HIPAA for each patient in accordance with hospital policy and federal regulations.
  • Supervises department to ensure safety in the workplace and a safe patient environment at all times
  • Ensures staff follow “minimum information necessary” when performing UR, case management, and discharge functions.
  • Recognizes the importance of documentation improvement and how it relates to the overall clinical function of the hospital regarding correct documentation of patient care, as well as fiscal reimbursement.
  • Responsible for the creation and maintenance of CDI (clinical documentation improvement)/coding queries and CDI policies.
  • Acts as a liaison for all facility patients/families, physicians, third-party payors and multidisciplinary team members to ensure positive experiences with facility services
  • Enforces compliance with all company, professional ,ethical, legal and accreditation/regulatory standards
  • Ensures and promotes individual patient privacy and confidentiality
  • Actively engage the organization’s mission, vision, values, and strategic initiatives and promotes implementation within the case management department.
  • Promotes compliance with the organization’s Quality, Risk, and Continuum of Care program philosophy.
  • Ensures compliance with all Case Management and UM policies and procedures via effective positive leadership.
  • Establishes audits and compiles statistics that demonstrate individual case management and department proficiency and compliance with all policies and regulatory statutes.
  • Leads the Initial Multidisciplinary Team Conference within 7 days of admission.  Continues to Co-Chair with Physician Advisor (or designee) ongoing weekly Team Conferences are held on each patient every 7 calendar days.
  • Collaborates with all interdisciplinary department directors to coordinate the multidisciplinary treatment plan to ensure initiation of a treatment plan, identify goals and interventions and establish discharge plans appropriate to medical, legal, and social issues present in accordance with patient/family needs.
  • Actively co-manages weekly UM meetings to review all DRG outlier cases for appropriateness of admission and discharge, as well as the need for continued stay.  Barriers are identified, and appropriate physician intervention is obtained when necessary.
  • Audits case management UM files to ensure all UM reviews are completed within time frames established in department policies.
  • Develops and audits all UM case management and physician reviews to ensure inter-rater reliability.
  • Audits clinical documentation to third-party payors to ensure all required levels, rates, days, etc. are
  • Documented timely.  Ensures when necessary cases are referred to a supervisor for additional supervisory intervention such as potential denials or appeals.
  • Ensures provision of case management, utilization management, and discharge planning equally to all patients regardless of payor source.
  • Audits all case management documentation in the chart to ensure timely documentation and to ensure all documentation follows policies.  Documentation will be completed to ensure all members of the multidisciplinary team fashion is aware of ongoing discharge planning progress or issues.
  • Audits to ensure referrals to PA and Medical Directors are initiated per UM policy.  Ensures documentation of all interventions and results of interventions are timely and documented per policy.
  • Provides ongoing supervision of individual case management cases to ensure appropriate and timely use of medical resources and implementation of discharge planning.
  • Provides training and oversight in using DRG and InterQual as tools to assist in the appropriate management of patient medical services and to facilitate discharge to the appropriate level of care in the most timely and cost-effective manner.
  • Supervises and assists in obtaining legible physician documentation in the medical record to support the current level of treatment, medical necessity of continued stay, and documentation of all current diagnoses being actively treated.  Specific treatment of these diagnoses should also be documented that further defines the need for continued acute care and the use of medical resources.
  • Manages staff and interfaces with other team members to ensure timely consultations with specialists, specialized services, or critical diagnostic tests are completed.  Actively assists case managers as appropriate in obtaining results to facilitate timely implementation of medical treatment.
  • Collaborates with the treatment team and patient/family to prevent duplication or fragmentation of services.
  • Conducts concurrent and retrospective reviews to identify and improve clinical, resource, and system problems utilizing the continuous improvement process.
  • Performs supervisor level UM review on individual patients when referred and reviews all cases referred to Physician Advisor or designee prior to referral being initiated.
  • Educates and supervises case managers to ensure and facilitates patient education as necessary to meet patient/family learning needs to ensure a safe discharge and increase continued treatment compliance.Consults assists and intervenes regarding the end of life for patients
  • Reports coordinate with and maintain APS/CPS logs of potential abuse and neglect for all patients in accordance with Federal, State, and organization policies.  This information is shared with Quality, who maintains the APS/CPS logs and assists with necessary follow up as appropriate.
  • Provides and maintains resource lists for case managers to share with patients and staff regarding financial and community resources for all age populations served. This tool will be maintained electronically to assist in the frequent updates as community resources change.
  • Supervises case managers via case reviews to ensure coordination and finalization of discharge plans to ensure smooth and timely discharge of patients.  Ensures all appropriate services and equipment are provided to ensure a safe discharge environment.  Ensures all discharge dispositions are appropriate to meet ongoing medical needs
  • Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system or community) which affect patient care, resource management or length of stay.  Completes statistical and other reports as required in a timely manner.
  • Managers the case management department to ensure the utilization of medical resources for patients will assist in the progression of patient recovery and is completed at the most appropriate time. Promotes through supervision the conservation of medical resources in accordance with medical needs.
  • Actively participates in Quality Improvement, UM Committee, and Risk Management program and promotes awareness of programs to promote quality, safety, and improved patient outcomes.
  • Ensures appropriate communication with all team members and department directors to meet organization mission, vision, values, and strategic initiatives.
  • Actively participates in organizational projects and programs by developing and implementing programs designed to increase the optimization of patient recovery and improved outcomes.
  • Acts as a mentor and coach to fully develop the performance of each individual case manager.  Provides departmental education designed to enhance knowledge and performance of case management responsibilities. Provide information to increase knowledge of regulations and enhance compliance with regulatory guidelines that govern case management functions.
  • Performs other duties as assigned.

Position Qualifications:

EDUCATION:

  • RN degree required
  • Bachelor’s or Master’s in Healthcare field preferred
  • Experience may be substituted for a degree(s)

EXPERIENCE:

  • 3-5 years of acute hospital direct patient care experience
  • Minimum of 5 years’ experience in acute hospital case management, LTAC case management experience preferred.
  • 2-3 years’ experience in an advanced management position in case management, LTAC experience preferred
  • Strong analytical and organizational skills
  • Proficient knowledge of all LTAC regulatory, managed care and accreditation requirements
  • Proficient in knowledge and ability to apply professional standards of practice in Case Management, RN and LMSW practice

LICENSURE/CERTIFICATION:

  • Current license as a Registered Nurse in the state of Texas.
  • Current CPR certification.
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Job Requirements