Director Care Management (RN)

Sutter Health•San Francisco, CA

11d•Onsite

About The Position

Responsible for care coordination operations for Sutter Health. Works closely with the interdisciplinary, physician and leadership team to align care coordination activities and achieve desired goals and metrics. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

Requirements

Bachelor's in Nursing OR Master's in Social Work OR Master's (or current enrollment with completion within 2 years) in Case Management or Health Administration with relevant acute hospital experience OR or evidence of enrollment in Master’s Degree program and completion within 2 years. (Social Work candidates must have Masters in Social Work)
RN-Registered Nurse of California OR LCSW-Licensed Clinical Social Worker
12 years recent relevant experience.
Knowledge of ACMA, CMSA & NASW Standards of Practice required.
Knowledge of available health care and community resources.
A broad knowledge base of health care delivery and case management within a managed care environment required.
Comprehensive knowledge of local, state and federal laws, regulations and professional standards affecting case management practice in an integrated delivery system.
Verbal and written communication skills.
Group presentation design and facilitation skills.
Demonstrated ability to develop and manage complex projects.
Ability to promote teamwork and to effectively function in teams, both as a leader and as a team member.
Ability to interact effectively with key internal and external constituents using collaboration, negotiation and analytical problem resolution skills.
Ability to work effectively in a fast paced environment, directing and managing multiple and complex projects.
Analytical and mathematical skills.
Demonstrated ability to implement continuous quality improvement processes and techniques, including benchmarking and outcomes measurements.
Intermediate to advanced PC skills, word processing, spreadsheets and PowerPoint required.
Strong problem resolution abilities and customer relation skills.

Nice To Haves

Working knowledge of InterQual criteria preferred.

Responsibilities

Effectively manages the activities of the care coordination team, providing leadership and guidance.
Designs, implements and evaluates staffing coverage based upon established case management ratios to serve population needs, volume and acuity of patients.
Monitors department activities, communicates policies, evaluates performance, and provides feedback, coaching, mentoring and discipline.
Identifies department goals and objectives, develops and communicates action plans through regular staff meetings and other communications, uses team approach to problem solving and sets clear expectations.
Identifies training needs and develops and participates in staff training, orientation and new hire onboarding.
Ensures provision of quality services by maintaining appropriate staffing resources, staffing levels, competency of staff and ongoing training and education.
Establishes linkages between care coordination and other internal entities and departments.
Delegates duties and projects appropriately, to produce successful results and growth and development opportunities for staff.
Develops succession plan for department.
Designs, implements and directs care coordination processes for effective coordination of health care services to achieve program goals and objectives.
Formulates program goals and objectives.
Supports the senior leadership in leading the change process at the entity level. Management/Population health management. This includes role changes, infrastructure changes, planning for new skills acquisition, expanded relationships with community resources, creative alternatives to inpatient admissions and improvement in capacity management.
Ensures that care coordination services are in compliance with accrediting, statutory, regulatory and facility-specific standards by implementing applicable policies and procedures.
Effectively communicates Sutter Health utilization management plan goals and objectives to the care coordination team and plans activities and strategy to support effective implementation and compliance.
Maintains awareness of high-risk complex cases to review/determine an effective and realistic plan of care.
Drives vision and direction through effective communication, sharing information, trending data and communicating outcome measurements.
Leads complex case review.
Monitors interdisciplinary rounds and identifies opportunities for improvement.
Develops monitoring systems, measurements and evaluation tools that support and guide the care coordination team.
Organizes and presents the care coordination model to internal and external groups.
Manages all operational processes to ensure an effective team will achieve desired goals, assisting the staff to remove barriers that impede progression of a patient’s plan of care.
Prepares accurate and timely capital and operating budgets and service projections for care coordination operations.
Manages the operations of the care coordination team to ensure cost effective utilization of department resources.
Facilitates complex clinical and financial decision making by presenting thoroughly analyzed cases requiring higher administrative approval or intervention.
Works with the representatives from entity analysis and finance departments to design and interpret utilization and financial performance reports and ensures compliance with reporting standards and regulations.
Tracks, analyzes and presents data at utilization management meetings. Interprets findings and proposes process improvements.
Advises and educates the care coordination team related to LOS , readmissions, difficult discharges and patient throughput barriers.
Monitors and tracks monthly budget for achieving budget goals and analyzing budget variances. Responsible for monthly budget variance reports.
Develops and administers strategic plans for achieving goals that are aligned with Sutter Health goals.
Performs staff rounds and monitors care activities to ensure compliance with the delivery of effective care coordination.
Communicates utilization issues/findings to senior leadership via reports, meetings and presentations.
Works with the payer communication staff in claims and billing departments to resolve complex claims and denials.
Discusses with payers and providers in securing coverage for medically necessary services.
Collaborates with care coordination leadership team to establish an integrated continuous quality improvement processes to assure high quality care, customer satisfaction and financial performance.
Develops and implements integrated measurement and evaluation systems to monitor program performance against established process and outcome measures.
Effectively incorporates new work processes and approaches to improve efficiency and quality of services.
Assures department specific safety program is in compliance with Sutter Health quality and risk programs.
Manages and monitors sensitive risk management issues.
Provides consultation regarding clinical, legal, and regulatory and reimbursement issues to case managers, physicians, and external entities.
Provides guidance to case management and social work staff in resolving problematic situations with clients and families, physicians and external entities.
Investigates and responds to client and provider complaints.
Participates as hands on team member and keeps team professionally current.
Coordinates clinical oversight for students and interns.
Keeps current on industry trends and research in practice.
Present new trends and best practices to the leadership for potential implementation.
Participates in and seeks educational forums for self and staff.
Regularly attends local and/or national meetings/conferences.
Participates in and involves staff in professional organizations.