Director, Inpatient System Care Management
Alameda Health System
- Oakland, CA
- Permanent
- Full-time
- 100% employer health plan for employees and their eligible dependents
- Unique benefit offerings that are partially or 100% employer paid
- Rich and varied retirement plans and the ability to participate in multiple plans.
- Generous paid time off plans
- Accountable for Patient Care Coordination activities including system-wide Case Management, Care Coordination and Discharge Planning.
- Aligns Case Management with AHS strategic and operational objectives.
- Optimizes efficient Care Management/care coordination roles and processes; initiates process improvements.
- Develops, monitors and evaluates inpatient Care Management Metrics; manages the collection, analysis and presentation data relevant to the utilization of healthcare resources including but not limited to avoidable/variance days, readmissions, one-day stays, DRGs, LOS.
- Develops, maintains and implements Case Management policies, practices and procedures in accordance with CMS, CA DCHS, the Joint Commission, Title 22 and other regulatory agencies and overall hospital policies; integrates managed care contract criteria into overall Case Management functions.
- Works closely with the VP of Care Management and Physician Advisors on any audits and secondary reviews; may include but not limited to Direct and coordinate data gathering, chart audits and participants in internal and external meetings.
- Oversees educational needs and plan for inpatient Care Management division.
- Recruits, trains and coaches the management staff to assist them with performing optimally and provides appropriate discipline/structure; consults and assists Care Management managers with problem solving with staffing, personnel issues, budget issues and resource management; reviews and evaluates management staff performance, initiate personnel transactions and meet hospital standard for performance evaluations.
- Supports the VP of CM with completion of financial analyses including cost of care to reimbursement, denials management, and non-reimbursed services, promoting effective resource utilization, clinical documentation/queries quality care and patient safety; oversees the Inpatient recovery process; works closely with Revenue Cycle and AHS Physician Advisors; regularly communicates with payors and/or their contracted vendors.
- Responsible for the coordination and support of the AHS Utilization Review Committee.
- Responsible of overseeing patient, physician and staff satisfaction based on quality outcomes and patient experience reporting; in conjunction with the Quality Leadership, identifies utilization issues affecting the quality of patient care.
- Provides AHS physicians, nursing and staff education including InterQual® criteria methodology, resource management, medical necessity guidelines payer sources, clinical outcome metrics, length of stay initiatives, readmission strategies, reimbursement rules and medical record documentation requirements.
- Serves as Content Expert/Liaison to community agencies, AHS and Non AHS primary care provider network and all AHS stakeholders across all AHS facilities (i.e. Nursing and Hospital Administrators) for provision of care and services across the continuum of care.
- In conjunction with department managers and/or supervisors, coordinates, develops, and implements action plans to respond to areas felt to be in need of improvement related to patient flow and care coordination across the continuum.
- Assumes accountability for improving utilization metrics associated with department/unit and meeting organizational/departmental targets.
- Evaluates, plans, and executes changes in department procedures, equipment and supplies.
- Performs all other duties as assigned.
- Required Education: Master's degree in Nursing or Master's degree in Social Work or related field.
- Required Experience: Seven to ten years of case management or quality experience in addition to progressive management experience in a large healthcare organization is required.
- Preferred Experience: N/A