Director, Utilization Review and Social Worker Services Exempt

Hollywood Presbyterian•Los Angeles, CA

2h•$200,000 - $235,000

About The Position

CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility serving the Hollywood community and surrounding areas since 1924. The hospital provides quality medical and nursing care to local multicultural communities and is part of a global healthcare enterprise with hospitals, research centers, a medical university, and CHAUM. The Director has overall responsibility for hospital utilization management, transition management, and the operational management of the Case Management Department. The role promotes effective use of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with applicable state and federal regulations. The position integrates utilization management, transition management, care coordination, regulatory compliance, and education for physicians, patients, families, and caregivers. It oversees the hospital Utilization Management Plan and uses data to improve utilization performance. The role also addresses behavioral and psychosocial needs through social work interventions, supports members in accessing resources and managing healthcare needs, coordinates behavioral health resources, and works collaboratively with the Vice President of Revenue Cycle on financial matters. The role may provide leadership to the Health Information Management Team at the direction of the COO.

Requirements

Bachelor's degree in Business, Nursing, or Health Care Administration for an RN, or a Master's degree in Social Work for an MSW.
Active RN or LCSW/LMSW license; must be currently licensed, certified, or registered to practice as required by law, regulation, or policy in the state of practice.
Three years of acute hospital case management or healthcare leadership experience.
Ability to communicate effectively verbally and in writing.
Ability to work in a union environment.
Demonstrated organizational skills.
Ability to lead and coordinate activities of a diverse group in a fast-paced environment.
Critical-thinking and problem-solving skills.
Computer literacy.
Los Angeles County Fire & Safety Card required within 30 days of hire.
Assault Response Competency (ARC) required within 30 days of hire.

Nice To Haves

MSN, MBA, MSW, or MHA.
Accredited Case Manager (ACM) certification.
Five years of acute hospital case management leadership experience in a multi-site environment.
Business planning experience.

Responsibilities

Oversee hospital utilization management, transition management, and Case Management Department operations.
Promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe patient throughput, and regulatory compliance.
Support medical necessity and denial prevention through utilization management.
Promote appropriate length of stay, readmission prevention, and patient satisfaction through transition management.
Coordinate care to support efficient throughput and care at the appropriate sequence and level.
Ensure compliance with state and federal requirements, TJC accreditation standards, and HPMC policy.
Educate physicians, patients, families, and caregivers.
Manage department operations to support effective throughput and reimbursement for services provided.
Lead implementation and oversight of the hospital Utilization Management Plan and use data to drive utilization performance improvement.
Ensure medical necessity and revenue cycle processes are accurate and comply with CMS regulations and HPMC policy.
Ensure timely and effective patient transitions and planning.
Implement and monitor processes to prevent payer disputes.
Develop and provide physician education and feedback on hospital utilization.
Participate in management of the post-acute provider network.
Use available community, government, and client resources to address participants' limitations or support chronic-condition interventions.
Manage behavioral and psychosocial needs, provide social work interventions, and support improved clinical and financial outcomes.
Help members use available resources to meet personal health needs and develop their capabilities.
Evaluate members' ability to manage independently and locate alternative resources through Social Work Psychosocial evaluations.
Guide members seeking solutions to social, cultural, or financial problems affecting their ability to manage healthcare needs.
Evaluate members' strengths in health self-management, develop supportive strategies, and implement plans in support of case decisions.
Facilitate and coordinate behavioral health resources according to member needs.
Collaborate with the Vice President of Revenue Cycle on financial matters.
May provide leadership to the Health Information Management Team at the direction of the COO.
Perform other duties as assigned.