Job Details

Description

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DMC Sinai-Grace Hospital is DMC’s largest hospital, offering a comprehensive heart center, cancer care, gerontology, emergency medicine, obstetrics/gynecology and cosmetic services. Sinai-Grace’s joint replacement program features a revolutionary minimally invasive knee and hip replacement surgery that attracts patients from all over the country. Sinai-Grace operates more than 21 outpatient care sites and ambulatory surgery centers throughout Wayne and Oakland Counties and is one of 10 hospitals in the nation to be awarded a Robert Wood Johnson Foundation grant to help set the standards of cardiac care for hospitals and physicians throughout the nation.
Summary Description
The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination. The individual in this position has overall responsibility to ensure staff assess patients for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:

• Provides assistance to the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
• Utilization Management supporting appropriate use of resources
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
• Compliance with state and federal regulatory requirements including state psychiatric holds (Baker Act, 5150, etc.), TJC accreditation standards and Tenet policy
• Provides education to physicians, patients, families and caregivers

POSITION SPECIFIC RESPONSIBILITIES:
Department Operations

• Oversees an adequate number and skill mix of staff over seven days a week to serve the patient population and meet the goals of the department
• Supports and manages staffing requests utilizing the Tenet Case Management staffing recommendations within budgetary guidelines
• Plans and conducts regular departmental meetings with the Director to provide staff updates and ongoing education

• Ensures new Case Management staff complete department orientation including review of Tenet Case Management and Compliance policies and Documentation training

• Assists the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments

• Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.

(30% daily, essential)
Utilization Management

• Monitors the review process to ensure staff follow Tenet policy and process for appropriate patient status and level of care
• Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
• Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services

• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Assists the Director in monitoring to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
• Identifies and documents Avoidable Days using the data to address opportunities for improvement
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.

(20% daily, essential)
Transition Management

• Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Ensures case management staff use electronic referral request process for patient placements
• Monitors to ensure that patient preference & choice is documented per CMS regulations and Tenet policy
• Monitors to ensure case management staff document in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
• Ensures staff are completing comprehensive assessments within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
• Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work and/or Complex Case Review
• Ensures all elements of the transition plan are implemented and