Responsible for the oversight, management and optimization of all quality improvement, utilization management and care management activities as it relates to pre-admission, ambulatory case management, inpatient, social service, home health, health education, behavioral health and other health care delivery programs within Health Care Partners Medical Group. Manages staff directly responsible for the day-to-day operations of the care management programs. Contributes to the clinical, quality, financial and patient satisfaction outcomes of the region. Works closely with all members of the Care Management team as well as members of Health Enhancement, Quality Improvement, Contracting and the Office of the Medical Director to ensure compliance with all regulatory requirements.
- Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
- Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the region.
- Monitors the utilization of inpatient and outpatient services and ensures coordination of all ambulatory care management services with pre-admission, home health, health education and other ambulatory services.
- Closely monitors and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Vice President/Director, Regional Care Management regarding interventions to improve all resource management.
- Facilitates team process problem resolution using HCP administration, Medical Directors, Contracting, Risk Management, Behavioral Health and health plans regarding complex patient issues. Implements the results of the collaboration process.
- Oversees and monitors patient eligibility, financial contract accountability and health plan benefit determination for each patient referral. Facilitates resolution on areas of conflict.
- Prepares the department for accreditation surveys using the appropriate standards of performance. Ensures utilization management compliance with DMHC/CMS/NCQA requirements.
- Leads activities related to the utilization review process in conjunction with the local Care Management Committee Provider Chair.
- Designs, implements and facilitates data and statistical collection including outcome and quality of care information.
- Monitors all high risk/high cost patients in regard to care delivery, referrals, contracting, etc. Monitors provider referral patterns for appropriate utilization of specialty and ancillary services.
- Provides supervision and guidance to Supervisor and staff reporting to the position.
- Conducts monthly staff meetings including utilization management review outcome measurements and identification of training/educational opportunities.
- Identifies, develops and oversees the educational needs of Care Management staff, providers and others. These include an extensive orientation program, cross-training and proactive approach to case management.
- Identifies opportunities for the development of new care management approaches and prepares proposals with cost analyses, IS requirements, education and implementation plans.
- Contributes to the Care Management business plan and budget process along with the Vice President/Director, Regional Care Management.
- Coordinates or performs projects/activities as delegated by organizational committees and Vice President/Director, Regional Care Management.
- Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.
- Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
- Graduate from an accredited school of Nursing.
- Current California RN license.
- Bachelor’s degree in Nursing or related field preferred.
- Over 3 years and up to and including 5 years of experience.
- 3 to 5 years prior acute nursing experience.
- 3 to 5 years prior acute nursing with critical care experience.
- 2 to 4 years managed care/HMO experience in utilization review, case management or discharge planning.
- 2 to 3 years management experience in utilization review, case management or discharge planning.
Knowledge, Skills, & Abilities:
- Computer literate.
- Proficient in Microsoft applications (Word, Excel, Access).
- Knowledge of medical/nursing standards of care.
- Working knowledge of CMS, NCQA, DMCH, HEDIS, medical and regulatory agency guidelines.
- Excellent verbal and written communication skills.
- Ability to effectively collaborate with physicians, patients/families and ancillary staff.
- Strong oral/written analytical and problem-solving skills with ability to make sound and independent judgments.
- Ability to act professionally under pressure.