POSITION SUMMARY:
Under supervision of the Vice President of the Integrated Resource Management Department, the Director manages the functions of the Resource Management program. The position is accountable to supervise the daily activities of Resource Management staff and is responsible for other duties as defined by the Vice President. The Director is on-site, available seven days a week and carries a cell phone for after hour, weekend and holidays.
POSITION EDUCATION/ QUALIFICATIONS:
· Bachelor’s degree required
· Must possess a strong knowledge of nursing, case management or healthcare related field.
· Certification in Case Management preferred, or must achieve certification within 3 years of hiring.
· Supervisory experience required, 2-4 years preferred.
· Previous experience in Case Management and Discharge Planning or equivalent required.
JOB KNOWLEDGE/EXPERIENCE:
· Requires knowledge in the areas of case management and utilization management. Experience with Managed Care preferred. Knowledge of utilization management as it relates to third-party payers.
· Experience in use of InterQual and or Milliman criteria and review processes.
· Knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review and discharge planning.
· Demonstrated skills in the areas of negotiation, excels in communications (verbal and written), conflict, interdisciplinary collaboration, creative problem solving, and critical thinking. .
· Knowledge of health care financing, and data analysis.
· Must have a working knowledge of hospital operations, medical/nursing staff procedures, and hospital and community resources.
· Requires leadership skills and an ability to interact well across departments, facilities and organizations.
· Organizational, human relations, and communication skills are required
· Computer skills required with knowledge of Microsoft Office Suite.
· Bilingual – English/Spanish preferred.
POSITION RESPONSIBILITES:
· Provides leadership, education, and mentoring of Resource Management Staff.
· Provides training within the department on topics relevant to the services provided.
· Coordinates the planning of schedules, work assignments and directs the workflow for the staff.
· Participates in hiring, and oversees orientation of new staff.
· Provides/oversees training program of BSW as required by the State of Texas.
· May be called upon to undertake supervision of students, trainees or staff.
· At regular intervals reviews pertinent medical records/ logs to ensure that all information is complete
· Performs evaluations of the staff in concert with the Administrator.
· Develops corrective actions plans with staff not meeting expectations of their respective position.
· Reviews policies annually to make sure they reflect current standards and regulations.
· Participates in the development of the department budget.
· Represents Resource Management at hospital committee and work groups as requested by the Administrator.
· In accordance with departmental policy, will be required to attend relevant training courses and staff developmental programs when these are made available and recommended by senior staff/training officers.
· Maintains personal competencies needed for licensure and attending internal and external educational offerings.
· Evaluations are completed timely and provide goal setting for the future year
· Work schedules are completed timely and reflect adequate staffing.
· Provides leadership functions in absence of Vice President of Integrated Resource Mgt.
· Review biweekly staffing schedule.
· Maintains supplies equipment.
· Requests for PTO.
· Maintains departmental staffing within established budget.
· Collaborate with the multidisciplinary team to assure effective, efficient, appropriate care in order to optimize the health status and assure a smooth transition between levels of care for patients served.
· Manages staff performance related patient's transition through the system and transfers accountability to the appropriate person upon entry into another clinical service or upon discharge.
· Participates in rounds on nursing units to observe and provide direction so as to facilitate maintain resource consumption.
· Serves as a resource to associates/physicians/ Case Managers and Social Workers on issues relating to utilization of services and discharge planning.
· Assists in facilitating and implementing physician orders to aid in the timely completion of patient care along the continuum.
· Provides training within the department on topics applicable to the services provided
· Performs quality assessment reviews and studies both concurrently and retrospectively as required by the hospital’s PI plan, TJC standards, CMS and third-party payer regulations.
· Applies generic quality screens/indicators concurrently to patient medical records and accurately abstracts relevant patient care data to determine if quality screens are flagged. Performs first line reviews on potential quality issues as requested by the Administrator.
· Refers all other potential quality of care issues identified, not reviewed, as part of the quality assessment screening to the physician advisor to facilitate timely follow up.
· Monitors and oversees avoidable day data for system Performance Improvement
· Refers quality issues to the Resource Management Administrator, CMO and/or PA appropriately.
· Identifies and reports opportunities to improve care for patients, including patient complaints and any unusual patient care issues.
· Assists the Vice President in establishing and maintaining an effective Denial Management Program and process
· Organize and conduct meetings and training sessions.
· Member of Denial Management Team
· Data Management
· Demonstrate ability to collect, analyze and present data accurately as appropriate to position
· Prepare clear and concise oral and written reports
· Organize and provide materials in compliance with laws, regulations and policies
· Provide at minimum, monthly reports to Leadership, of discrepancies and other data as requested.
· Maintains current knowledge of case management, utilization management, and discharge planning, as specified by federal, state, and private insurance guidelines.
· Maintains a working knowledge about the requirements of the payers most frequently seen with the patient population
· Maintains a working knowledge of the resources available in the community for patients/families.
· Maintains current nursing licensure CEU credits.
· Maintains knowledge of InterQual and Milliman criteria.
· Performs related duties as required
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Retirement plan
- Vision insurance
Education:
Experience:
- Case management: 1 year (Preferred)
- Supervising: 2 years (Required)
- Hospital: 1 year (Required)
- Discharge planning: 1 year (Required)
- Acute care: 3 years (Required)
License/Certification:
- Nursing Case Management Certification (Preferred)
Work Location: In person
