Job Description Responsible for the daily operations of the Care Management department including utilization review, denials and appeals, care coordination, and medical discharge planning. Focuses teams around identifying barriers to care progression along with developing and executing timely discharge plans to optimize clinical outcomes within best practice. Promotes and mentors team knowledge through the continual advancement of skills necessary for their professional development. Leads performance improvement initiatives with key members of the organization for utilization processes, trends and regulatory requirements of utilization management. Facilitates processes that connect the inpatient care coordination with the ambulatory care coordination programs. Responsible for strong collaboration of care coordination services with the Kootenai Care Network, ambulatory clinics and post-acute facilities. Responsible for establishing appropriate staffing levels and work assignment's, developing performance criteria for staff, serving as an expert resource for regulatory compliance, policies, and operational procedures. Interfaces with professionals from multiple disciplines assuring quality patient care coordination is at an optimum across the continuum and at a resource-appropriate level of care. Familiar with standard concepts, practices, and procedures within the field of case management. Relies on experience and judgment to plan and accomplish goals. A certain degree of creativity and latitude is required. Performs other related duties as assigned.
Age/Patient Population(s) Served Key Age of Patient Population Served Neonate (birth - 28 days) Infant (29 days - less than 1 year) Pediatric (1 - 12 yrs) Adolescent (13 - 17 yrs) Adult (18 - 64 yrs) Geriatric (65 yrs & older) Nonage Specific Task (N/A) Population Bariatric Patients: BMI greater than 40, or greater than 35 with weight related comorbidities Patient with exceptional communication needs Patient with developmental delays Patient at the end of life Patient under isolation precautions All Populations
Minimum Qualifications: 1. Licensed R.N in the state of Idaho. BSN required, Masters preferred 2. ACM or CCM certification preferred 3. 5 years' acute hospital experience as direct care clinician or case manager and 1 year experience in non-hospital based health care required 4. 5 years' supervisory or management experience required Demonstrated knowledge of laws or regulations pertaining to the utilization review, reimbursement programs, quality and financial outcomes of patient care processes and accreditation required Knowledge of insurance, coding, compliance practices and data analysis required 7. Computer skills in Microsoft office and ability to learn multiple operating systems is required 8. Previous experience in utilization management, case management, project implementation, insurance practices and regulatory compliance preferred
Essential Job Functions (Physical Requirements): Regular and predictable attendance is an essential job function. · Intermittent sitting and walking throughout scheduled shift. · Ability to lift up to 25 pounds. · Frequent stooping, bending, reaching, lifting when filing and accessing records. · Read charts, dials, equipment settings, literature and other printed and handwritten materials. · Communicate with patients, physicians, families and co-workers in person and on telephone. · Work with equipment and manipulate equipment settings, computer keyboard, etc.
Work Environment: · Kootenai health operates 24 hours per day each day of the year; operational needs of departments may require that you be available to work all shifts, weekends and holidays to meet the needs of the patients. Work is normally performed in a typical interior work environment
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