DescriptionSHIFT: No Weekends
Responsible for managing and coordinating the overall Case Management/Clinical Pathway Program.
Must follow and adhere to all federal and state laws and regulations, as well as the HCA Code of Conduct and SBMC Performance Standards.
Supervises, assigns and directs the activities of the Case Managers.
Develops policies and procedures pertinent to Case Management.
Makes necessary revisions of the plans, policies, procedures and any forms necessary to document activities of the program.
Assists Chief Financial Officer in setting goals and objectives, and updates them in a timely manner.
Assists with the department budget annually.
Establishes effective lines of communication and maintenance of a good professional rapport with the Medical Staff, Administration, Nursing, and all other departments.
Reviews departmental activities and summary reports to assist in problem identification.
Assists with problem solutions, and monitors corrective intervention follow-up action and results of action.
Reviews all denials received from TMF and 3rd party payors and presents actual case studies to the Case Management/Medical Records Committee, and coordinates TMF and 3rd party payor appeals with the Medical Staff.
Reviews financial reports of Medicare and Medicaid patients. Identifies problem DRGs , and departments that are encountering utilization problems and makes recommendations to resolve identified problems.
Discusses when necessary and offers solutions when possible to resolve with patients and/or family any grievances with the hospital in order to eliminate or diminish potential liability claims.
Assures that all Case Management activities are integrated and undergo the appropriate and Peer Review process via the Case Management program.
Ensures Case Managers are involved in IOP Teams.
Assures that all JCAHO and other regulatory agency requirements are met.
Provides educational and technical assistance to all hospital departments and Medical Staff.
Provides updated information relating to DRGs, HCFA regulations, legislative requirements and JCAHO standards to Administration, Medical Staff and hospital departments.
Evaluate the performance of the Case Management personnel annually.
Performs an annual review of all Case Management programs.
Participates in appropriate inservices and meetings.
Performs other responsibilities as directed or needed by the Chief Financial Officer and/or the hospital.
Analyze data through the Quality Services Department to determine target diagnosis.
Ensures that Case Managers establish methods of tracking the patient’s progress through the health care system, within the episode of the illness.
Collect and analyze patient demographic and variance data.
Analyze LOS, average cost and patient outcomes.