JOB SUMMARY

The Transitions of Care Supervisor is full time position. The supervisor is a health care professional with experience and background to assure compliance with CMS Conditions of Participation regarding Utilization Review, Discharge Planning, and social work. She/he will supervise the process, and at times, complete the assessment to identify the patient's clinical needs to be accommodated and construct a care plan to include DME, Outpatient Physical Therapy, Anti-biotic regime, etc. The Transitions of Care Supervisor follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.

The Transitions of Care Supervisor oversees a team of case managers and social workers, ensuring that they provide effective and efficient service to patients in need of guidance, support, and resources. This role involves coordinating the team’s efforts, monitoring the quality of care and service provided, and implementing strategies to meet organizational goals. By fostering a collaborative environment, the supervisor ensures that case managers and social workers are well-equipped to address the diverse needs of their clients, facilitating a comprehensive approach to service delivery. Through leadership and oversight, the Transitions of Care Supervisor plays an integral role in ensuring that clients receive the support they need to navigate their challenges, while also contributing to the continuous improvement of the organization’s service standards.
 
The Transitions of Care Supervisor evaluates patient's care delivery process while in the hospital, as well as performs denial management either during admission or post discharge. S/he acts as a resource to the interdisciplinary team providing clinical expertise in the areas of utilization review, status determination, clinical resource utilization, the discharge planning and appeal/denial management.

*As a Transitions of Care Supervisor, you will be required to check your WhidbeyHealth email at minimum 3 times a day and utilize TEAMS messaging.

The Transitions of Care Supervisor is a working supervisory position and requires exceptional clinical judgement, time management, and communication skills.

PRINCIPLE FUNCTIONS includes the following, other duties may be assigned:

Oversee the daily operations and workflow of case managers and social work, ensuring efficient and effective delivery of services to clients. Develop, implement, and review policies and procedures to enhance the quality of case management services. Facilitate regular team meetings to discuss case progress, challenges, and strategies for improvement. Allocate caseloads and assignments to case managers and social workers, ensuring a balanced workload and appropriate matching of client needs with case manager expertise. Liaise with external agencies, stakeholders, and service providers to coordinate resources and services for clients. Manage and resolve complex cases and client issues that are escalated by the Transitions team. Prepare and analyze reports on case management activities, outcomes, and service utilization to inform strategic planning and decision-making. Collaborating in the implementation of Transitions of care management policies to foster a positive and organized work environment while planning, prioritizing, and assigning health care tasks to clinical support team members. Managing communication within the Transitions of care team to avoid errors and miscommunication. Assists manager in the development and execution of monthly schedule, timecard management, and shift change requests in manager absence. Addresses departmental and interdepartmental issues as needed with manager support. Maintaining knowledge of current trends in Transitional care management nursing and educating teams. Communicating with patients and their family members as needed and offering emotional support and compassionate care to patients and families in distress. Assessing, processing, and discharging patients in accordance with WhidbeyHealth policies and procedures. Maintaining patient with a focus on following HIPAA regulations and quality standards. Have a positive attitude and a propensity for leadership and team building with the ability to problem solve under pressure. Providing a direct line of communication between patients, nursing staff and physicians Acts as an interdisciplinary team member within the Transitions Department. Performs pre-admission status recommendation review for multiple care settings as assigned (i.e., Emergency Department, Direct Admission/Transfer, and/or elective procedure), to communicate with providers status guidance based on available information. Completes an initial needs assessment when a patient is admitted, in observation status or any other time deemed necessary by the interdisciplinary team. May contact providers, programs, and or agencies to who the patient has been referred to verify adherence to the discharge plan; follow up may be indicated for patients who have been identified as high risk for re-hospitalization or non-compliance with recommended follow up care. Attempts to contact discharged patients within 24 hours of discharge for follow-up. Ensures appropriate patient status upon admission and manages patient status conversions, as appropriate. Ensures completion of admission medical necessity reviews within 24 hours of admission. Completes concurrent inpatient medical necessity reviews daily, unless otherwise specified by payer. Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily). Completes Medicare extended stay reviews, as appropriate. Identifies and escalates all 1MN and 2MN Medicare IP stays. Collaborates with Care Management (CM) team, as appropriate (i.e., extended observation stays, patients no longer meeting medical necessity, status changes). Collaborates with physicians, as appropriate (i.e., to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.). Collaborates with payers, as appropriate (i.e., discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization, etc.). Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate. Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to Physician Advisor or designated leader, as appropriate. Assists with discharge appeal process, as appropriate. Provides timely and continual coverage of assigned work area to ensure all accounts are complete. Assists in the identification of Avoidable Days and LOS (length of stay) and communicates information with CM, as appropriate. Communicates with providers directly to notify of appropriate status. Obtains and transcribes telephone orders to change patient status in accordance with WhidbeyHealth policies, as well as monitors for authorization by the physician. Complies with all documentation requirements. Follows up on action items prior to the end of shift. Maintains a working knowledge of payer contracts and regulatory requirements and UM specific changes (i.e., changes in authorizations, payer contracts, CMS regulatory requirements included, but not limited to LOS, Medicare important message, etc.). Completes all tasks within department guidelines. Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies. Provides support regarding Medicare documentation requirements. Obtains telephone admission orders from physicians and monitors for authorization by the physician. Participates in the delivery of regulatory forms to patients when appropriate included but not limited to the Medicare important message, notice of non-coverage, hospital issued notices of non-coverage, etc. Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays. Actively participates in clinical performance improvement activities and utilization review committee. Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals. Supports the vision, mission, and values of the organization in all respects. Supports Value Improvement Practice principles of continuous improvement with energy and enthusiasm, functioning as a champion of change. Provides and maintains a safe environment for caregivers, patients, and guests. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings. Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate. May perform additional duties of similar complexity within the organization, as required or assigned.

 

JOB KNOWLEDGE & QUALIFICATIONS

Education

Graduate of an accredited school of nursing, BSN preferred.

Training and Experience

RN: Minimum 5 years’ experience as an RN of which two years’ experience is in utilization review, case management and/or discharge planning in a hospital inpatient acute care unit, health plan or a combination of both. Experience using MCG or InterQual Criteria to determine appropriate level of care preferred. Experience using clinical documentation to make recommendations regarding the most appropriate route of payment resolution, up to and including writing appeal letters. Ability to construct and document a succinct, assertive, and fact-based clinical summary to support medical necessary criteria. Must be able to work as an independent problem solver. Excellent interpersonal and communication skills are imperative.

Certificates, Licenses, Registrations

Washington State DOH License Required: RN   Current BLS HCP required. Certified Case Manager (CCM) or Accredited Case Manager (ACM) Preferred MCG Certification preferred   Benefit Information and Wage Transparancy:  WhidbeyHealth Employees who work a 0.5 FTE or higher are categorized as, “benefit eligible”.

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Wage Range: $92,000 - $154.545.30