Manager, Care Management

Sutter Health•Jackson, MS

28d•$150,301 - $240,490

About The Position

Manages the overall operations of the department for Sutter Health entities in accordance with current federal and state regulations and guidelines. The role works frequently with administrative and nursing leaders, risk management and ethics staff, ancillary services, revenue cycle and finance leaders, medical directors and staff, physicians, contracted providers, community resources, post-acute agencies, patients, and families. The manager leads the Care Coordination team and directs processes for effective coordination of health care services, cost-effective resource use, continuous quality improvement, customer satisfaction, and financial performance. The role develops and communicates program goals and action plans, monitors performance and outcomes, manages budgets and staffing, addresses complex clinical, financial, legal, risk, ethics, regulatory, and reimbursement matters, and supports efficient transitions of care. The manager also participates as a hands-on team member and keeps current on industry developments and professional practices.

Requirements

Bachelor's degree in Nursing or Health Administration, or a master's degree in Nursing, Case Management, or a related field; a Master of Social Work is accepted for Social Work candidates only.
California Registered Nurse (RN) license upon hire, or Licensed Clinical Social Worker (LCSW) license upon hire.
Eight years of recent relevant experience.
Knowledge of ACMA, CMSA, and NASW Standards of Practice.
Knowledge of available health care and community resources and broad knowledge of health care delivery and case management in a managed care environment.
Comprehensive knowledge of laws, regulations, and professional standards affecting case management in an integrated delivery system, including CMS, Title 22, CHA Consent Manual, CDPH, and TJC.
Verbal and written communication skills, including group presentation design and facilitation.
Demonstrated ability to develop and manage complex projects.
Working knowledge of InterQual criteria, MIDAS, and an E.H.R.
Ability to promote teamwork and function effectively as both a leader and team member.
Ability to collaborate, negotiate, and use analytical problem resolution skills with internal and external constituents.
Effective human relations and interpersonal skills to lead diverse health professionals toward program objectives.
Ability to work effectively in a fast-paced environment and direct services at multiple locations.
Analytical and mathematical skills.
Demonstrated ability to implement continuous quality improvement processes and techniques, including benchmarking and outcome measurement.
PC skills, including word processing, spreadsheets, and managed care software programs.
Strong problem resolution and customer relations skills.

Nice To Haves

Experience with EPIC is preferred.

Responsibilities

Manage Care Coordination team activities, providing leadership and guidance.
Determine staffing levels, interview candidates, and recommend hires; orient, train, assess, evaluate, coach, and address staff performance.
Establish department goals and objectives, communicate action plans, facilitate team problem solving, and set clear expectations.
Identify staff training needs, participate in training, delegate appropriately, and seek additional training opportunities.
Develop monitoring systems and measurements for the Care Coordination team and promote customer service.
Design, implement, and direct Care Coordination processes to coordinate health care services and achieve program objectives.
Ensure services comply with applicable accrediting, statutory, regulatory, and entity-specific standards and policies.
Communicate Utilization Management Program goals and action plans and plan strategies for implementation.
Share program direction, data trends, and outcome measurements with the organization; present the Care Coordination care model to internal and external groups.
Develop strategic action plans with management to address patient progression, throughput, access to care, and transitions-of-care barriers.
Assist with preparing operating budgets and monitor monthly budget goals, variances, and reports.
Facilitate complex clinical and financial decisions with the Director, escalating cases that require administrative approval or intervention.
Collaborate with Sutter Health management and local skilled nursing facilities to meet utilization and length-of-stay goals and facilitate transitions to post-acute levels of care.
Track, analyze, and present data to leadership; interpret findings and propose process improvements.
Communicate utilization findings to leadership through reports, meetings, and presentations.
Work with Patient Access, claims, and billing staff to resolve complex claims through resolution.
Negotiate with payers and providers to secure coverage for medically necessary and financially sound services.
Establish integrated continuous quality improvement processes and measurement systems to monitor program performance and outcomes.
Incorporate new work processes and approaches to improve efficiency and service quality.
Manage and monitor sensitive risk management issues and consult on clinical, legal, risk, ethics, regulatory, and reimbursement matters.
Guide staff in resolving problematic situations involving clients and families, physicians, and external entities; investigate and respond to quality-of-care complaints and assume responsibility for complex cases requiring administrative intervention.
Keep current on industry trends and developments; participate in educational forums and professional organizations and involve staff in these activities.
Participate as a member of the utilization Management committee (UMC).
Adhere to Sutter Health policies and procedures and support its philosophies and initiatives.