Position Summary:

Provides leadership and management of all operational aspects for Care Coordination including, but not limited to Case Management, Utilization Review (UR), Utilization Management (UM), and Medical Social Work. Provides leadership for interdisciplinary performance improvement activities throughout the organization and for the medical staff. Responsibilities include Robert Packer Hospital, Robert Packer Hospital Towanda Campus, Troy Community Hospital.

Education, License & Cert:

Bachelor of Science in Nursing required, master’s degree preferred. Certification in relevant field desired.

Experience:

Leadership experience in an acute care setting for at least five (5) years. Knowledge and ability to demonstrate understanding of Medicare/Medicaid regulations, Medicare Advantage UM rules/regulations, and Commercial payer rules/regulations regarding medical necessity, patient types, etc. Must be able to provide evidence of knowledge in and experience of payer contract language, as it relates to utilization management. Can navigate through the requirements imposed by all payers. Prior experience in Pennsylvania and New York payer environments is highly desirable. Prior experience in leadership/management, computer applications and systems activity required. Demonstrated effective communications, critical thinking and problem-solving skills required.

Essential Functions:

Assumes leadership and department head responsibilities for defined departments in: Employee hiring/Staffing/Performance feedback Manages two Care Coordination teams in three hospitals (RPH, TCH, RPH-Towanda Campus) with diverse regulatory requirements overseen by each state (PA and NY) Goal setting/PI planning/performance evaluation Daily operations Budget planning and management, monthly variance reporting Promotes care coordination/continuum of care for hospital patients Fosters collaborative relationships with internal departments/staff and external agencies/resources Resource for medical staff and other providers for identify best practice approaches and continuum care planning Provides oversight of documentation for continuum of care planning and interventions Utilizes data for decision making, PI planning, and strategic planning Responsible for the clinical Utilization Management component of the Revenue Cycle Assures UM related precertification/authorization process/requirements Minimizes and controls Hold Bills and denials related to UM team process Monitors/evaluates resource use (data) and implements performance improvement as necessary (i.e. LOS, level of care, Diagnostic testing, delays, etc.) External/Internal Audit management, response, and resolution Responsible for optimal usage, updating, maintenance of UR evidenced-based medical decision making tools Demonstrates ability to be a person of influence Builds trust among Multi-Disciplinary teams Provides leadership for implementing changes/performance improvement efforts Creates a work environment that enhances employee, patient and physician satisfaction Sets performance expectations/goals and maintains high standards of performance Develops knowledge and skills for providing a consulting role in the organization for performance improvement activities and processes. Maintains knowledge of regulatory requirements (federal, state, accrediting bodies) Understands and utilizes satisfaction data (patient, employee, physician) Facilitates committees and workgroups as required/necessary Supports medical staff initiatives Optimizes length of stay Assists with management of regional throughput measures and goals Assists with management of excess days Provides information to the organization regarding opportunities to reduce length of stay without harm to patients Oversees staff in the implementation of initiatives that reduce length of stay and improve patient flow Works with Medical Staff to improve patient flow and reduce the length of stay Provides appropriate information to address important UM objectives Maintains good relationships with medical staff by building trust and demonstrating reliability in the operation and practicing the values of the organization Supports evidence-based medicine Overseas Corporate Compliance Workplan, and Secondary Medical Necessity Reviewer program

Other Duties:

It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.