A Community Hospital in Alameda County ... and so much more For generations, Alameda residents have found friendly, familiar faces and dedicated medical attention at their local hospital. Now, more and more individuals in Oakland and throughout the East Bay are turning to Alameda Hospital for quality care. We welcome all patients seeking an Alameda County Hospital or Bay Area Hospital who value a state-of-the-art medical facility, with a human touch. Alameda Hospital. We care.
JOB SUMMARY: Responsible for the day to day operations of facility wide utilization, discharge planning and care coordination.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Manages and assumes responsibility for day to day operations of utilization management, care coordination and discharge planning activities.
2. Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff.
3. Reviews cases regularly with staff; acts as clinical consultant regarding care management issues; guides clinical staff with review of assessments and care plans, evaluates utilization reviews or documentation
4. Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
5. Oversees submission of any audits, including but not limited to MediCal, Medicare and internal compliance studies.
6. Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).
7. Conducts interdepartmental team conferences for identifying aberrant utilization; establishes a method of tracking variances based on critical timelines.
8. Assists Director in establishing, implementing and ensuring that care management policies, practices and procedures are in accordance with the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies.
9. Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects.
10. Manages process of pre-admission review of questionable admissions as referred by Admitting, Emergency Room and medical staff and offers workable solutions.
11. Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payors through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding care management issues.
12. Provides in house educational programs as needed for both staff and physicians.
13. Develops and provides statistical UM information and reports to appropriate committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality of patient care.
14. In conjunction with VP and Director, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum.
15. Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
16. Responsible to purchase, educate, and record education to new equipment and/or techniques.
17. Conducts and records periodic staff meetings, to inform staff of changes in policies and procedures.
18. Supervises technical procedures and performs procedures as needed.
19. Perform all other duties as assigned.
Required Education: Master's in Nursing or Masters in Social Work or Social Welfare
Required Experience: Five years of clinical nursing or social work experience in a directly related setting (e.g., acute care, skilled nursing, etc.); three years of case management experience; two years of experience in a supervisory or lead role.
Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California or licensed in Clinical Social Work in California, Active BLS - Basic Life Support Certification issued by the American Heart Association. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training.
Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM.