Job Summary: 

• Perform a comprehensive needs assessment of the patient's current condition while also assess and evaluate the patient's clinical symptoms and initial physician orders to determine whether or not the patient meets admission criteria.
• Recruit and assure competence of customer-focused staff, analyze, organizational performance issues, develop quality improvement indicators, and develop and maintain department budgets
• Utilize clinical nursing experience and knowledge in making timely assessments
• Assume the role of leader in planning, organizing, coaching and facilitating department functions and staff to ensure quality service during operational hours
• Accountable for the continuity of patient care.
• Review quality metrics and analyze and implement strategies to correct deficiencies and/or outliers.
• Provides leadership for the administration, direction and ongoing development of the Case Management department. 
• Ensuring that appropriate utilization of resources is accomplished through efforts that are cost effective, safe, clinically appropriate, and enhance quality of care. 
• Promotes and facilitates appropriate admission status, and facilitates movement through the healthcare continuum by implementing processes that ensure timely and proactive care coordination and discharge planning.
• Integrating department services with other departments and medical staff initiatives. 
• Prepare accurate reports and report results to the Utilization Review Committee
• Works with Epic Business Objects Reports and QMS Data Center to coordinate the collection, analysis and reporting of outcomes data.
• Coordinates performance improvement activities for the Social Work department. 
• Ongoing assessment of opportunities to implement initiatives to continuously improve care. 
• Ensures staff adherence to quality standards, customer service standards, and clinical practice standards
• Contract maintenance of InterQual and Milliman for efficiency and application of evidenced-based care. 
• Collaboration with the Data Center to select products that will interface appropriately with the hospital’s established systems

Skills on Resume: 

• Quality Metrics Analysis (Hard Skills)  
• Leadership (Soft Skills)  
• Resource Utilization (Hard Skills)  
• Care Coordination (Hard Skills)  
• Department Integration (Soft Skills)  
• Report Preparation (Hard Skills)  
• Performance Improvement (Hard Skills)  
• Collaboration with Data Systems (Soft Skills)  

Job Summary: 

• Directs and coordinates the daily operations of all case management staff assigned to provide supervision to sexually violent predators civilly committed pursuant to Chapter 841 of the Texas Health and Safety Code and provides training to case management staff.
• Develops goals for case management staff consistent with the agency's strategic plan.
• Oversees and develops comprehensive audit reports to evaluate staff compliance with goals, policy and procedures.
• Monitors multiple databases to ensure accurate employee data entry and provides technical guidance to employees.
• Prepares reports of compliance and takes corrective action when compliance is not achieved.
• Participates in the agency's strategic planning process through the identification of short- and long-term goals.
• Develops, drafts, reviews and approves agency policy and procedures related to SVP client supervision and treatment consistent with agency goals. 
• Implements policy and procedure changes to include training of staff and vendors.
• Investigates allegations of policy and procedure violations and documents findings and takes appropriate action to correct behavior
• Prepares or assists in the preparation of administrative reports, studies, and specialized research projects
• Works with the program staff in determining trends resolving technical problems and responds to emergencies.
• Represents the agency at meetings with outside entities and the public to provide training and technical assistance regarding civil commitment and to disseminate public information about the program.
• Responsible for the development and maintenance of the position descriptions, policies, and procedures of the department. 
• Participates in professional organizations relating to discharge planning and utilization review
• Actively promotes a positive image of The Christ Hospital with the public and professional community
• Direct and manage all Case Managers to include ongoing coaching, and supervision as well as disciplinary actions and Annual Evaluations.
• Oversee scheduling for clients to ensure caregivers are scheduled for shifts that are matched based upon experience, certification and personality

Skills on Resume: 

• Compliance Reporting (Hard Skills)  
• Strategic Planning (Hard Skills)  
• Policy Development (Hard Skills)  
• Staff Training (Soft Skills)  
• Investigation Management (Hard Skills)  
• Administrative Reporting (Hard Skills)  
• Emergency Response (Soft Skills)  
• Team Supervision (Soft Skills)

Job Summary: 

• Establishes, implements and evaluates a strategic plan for the department that takes into account internal and external factors and effectively communicates the plan throughout the organization
• Leads the Utilization Management Committee in conjunction with the Committee Chair and the QMS Executive Director, collaborates in the selection of standing agenda items, provides reports related data to be reviewed and/or requested data.
• Ensures that the Utilization Review Plan is current and compliant with CMS and other accreditation requirements
• Creates/Updates policies, procedures, and protocols for case management and social services
• Collaboration with Physician Advisor (PA) to ensure that evidenced based criteria are applied appropriately by the utilization review staff. 
• Assists clinical multi-disciplinary teams in the development and update of evidence-based clinical pathways.
• Develops structures and processes to facilitate participation by physicians, pharmacists, nurses, social workers and other health professionals in multidisciplinary care planning, care delivery, and discharge planning
• Participates in quality improvement processes and assures implementation of regulatory standards
• Ensure and oversee the process of patient admissions and transfers by ensuring proper level of care throughout the hospital stay and at discharge
• Develops annual departmental and capital budgets, monitors and analyzes ongoing performance and productivity and implements necessary corrective action plans
• Develops and implements a given strategic plan through reengineering and redesign of business processes and systems, including staffing, LOS, and accurate billing to increase revenues and reduce costs.
• Monitors, evaluates and controls appropriate utilization of budgeted FTE's and operational expenses
• Provide leadership focusing on achievement of organizational objectives and contractual delivery commitments specific to the delegated activities including but not limited to utilization management functions, utilization trends, QIO appeals processes and tracking, and provider appeals
• Oversee Hugh Daly Human Needs fund and Lazarow Schwartz Transplant Fund to maximize impact on patient care, LOS, readmission
• Establish data priorities and report formats that display critical outcome factors
• Delivers feedback to the departments regarding care coordination improvement opportunities identified through data outcomes
• Compile, analyze, and evaluate utilization management/review data. 

Skills on Resume: 

• Patient Admissions Oversight (Hard Skills)  
• Budget Development (Hard Skills)  
• Strategic Planning (Hard Skills)  
• Expense Management (Hard Skills)  
• Leadership (Soft Skills)  
• Data Prioritization (Hard Skills)  
• Care Coordination Feedback (Soft Skills)  
• Utilization Data Analysis (Hard Skills)  

Job Summary: 

• Ensures that improvement opportunities are appropriately channeled to effect change.
• Provides second level review and InterQual criteria screening for patients not being found to meet criteria, makes referrals to Physician Advisor as deemed 
• Participates as a team member in conference on behalf of patients, with other persons in the hospital, and the community in order to utilize all available resources 
• Facilitates interdisciplinary meetings to review patient progress toward goals, treatment and discharge plans.
• Maintains confidentiality of all pertinent patient information to assure patient rights is protected.
• Identifies Risk Management issues and reports issues as appropriate to Risk Manager.
• Facilitates and participates in unit meetings clinical meetings, and educational in-services to maintain/expand knowledge based on professional skills.
• Participates in continuing education to keep current with nursing and case management requirements and area-wide standards of care and certifications.
• Performs other duties as assigned to meet the needs of the department and hospital
• Attends weekly management meetings on time and participate as a team member
• Coordinates and responsible for all cardiovascular initiatives within the hospital
• Conducts regular meetings with supervisors for the purpose of communication, problem solving and evaluation of operations
• Attends management meetings on time and actively participates as a team members
• Adheres to the Standards of Behavior for Terre Haute Regional Hospital as per the Customer Relations Policy
• Planning, coordinating and supervising the activities of the staff, ensuring that all duties and responsibilities have been assigned and performed within the Case Management Department
• Provides facility specific LOS analysis and makes recommendations for process improvement. 

Skills on Resume: 

• Confidentiality Maintenance (Hard Skills)  
• Risk Management (Hard Skills)  
• Meeting Facilitation (Soft Skills)  
• Continuing Education (Soft Skills)  
• Team Participation (Soft Skills)  
• Cardiovascular Initiative Coordination (Hard Skills)  
• Staff Supervision (Soft Skills)  
• Operational Problem Solving (Soft Skills)  

Job Summary: 

• Provides leadership including ensuring medical necessity and third party authorization. 
• Identifies medical necessity issues relating to continued stay and works with patient care team to assure plan of care is addressing such issues in a timely, cost-effective manner
• Plans, coordinates, and supervises the work of interdisciplinary case management/discharge planning team identifying and implementing best practices.
• Maintains a working knowledge of Medicare/Medicaid rules and regulations regarding utilization review, reimbursement, discharge planning, transfer and home health requirements, as well as current trends and developments in utilization management.
• Provides facility specific LOS analysis and makes recommendations for process improvement and resource reduction strategies, capitalizing on facility and division best practices, ensures that improvement opportunities are appropriately channeled to effect change.
• Coordinates compliance initiatives with outside agencies such as Quality Improvement Organization (QIO) and Recovery Audit Contractors (RACs). 
• Facilitates the development and review of division/facility utilization management plans to ensure compliance with state and federal regulatory requirements. 
• Serves as spokesperson at all community functions regarding social work discharge planning issues as appropriate and as designated.
• Coordinated with Central Utilization Review to address and resolve issues related to facility utilization review process and denials. 
• Monitors and analyzes trends in the appeals/denials process.
• Facilitates strong working relationship between Revenue Integrity, hospital information systems (HIS), Bundled Care Payment Initiative (BPCI) program and patient admitting departments (PAS) to promote effective utilization management through coordination of efforts to ensure timely and cost-effective utilization of services.
• Facilitates URCommittee meetings and reports findings to Medical Executive and sub committees of the medical staff. 
• Maintains and updates hospital UR plan.
• Maintains a working knowledge of national criteria, such as InterQual and Milliman to assist in criteria review activities. 
• Trains case management staff in criteria sets.
• Develops length of stay (LOS) and resource reduction strategies, capitalizing on facility and division best practices. 

Skills on Resume: 

• Utilization Management (Hard Skills)  
• Regulatory Compliance (Hard Skills)  
• Community Engagement (Soft Skills)  
• Trend Analysis (Hard Skills)  
• Cross-department Coordination (Soft Skills)  
• Committee Facilitation (Soft Skills)  
• Criteria Review Knowledge (Hard Skills)  
• Staff Training (Soft Skills)