Nurse Manager, Clinical Resource & Community Care - Full Time - DC

POSITION SUMMARY

The Manager, Clinical Resource & Community Care Management will report to the Director of Integrated Care Management. The Manager will lead, supervise, and evaluate the daily work of the Children's National Rehabilitation and Specialized Care Nurse Care Management and Social Work team, and Community Health Programs within the enterprise in accordance with departmental and organizational policies. Provide education within the inpatient setting and community health programs, departments, and the organization at large on clinical care, levels of care, and financial issues. Lead the clinical and financial processes that impact authorization for inpatient and outpatient services, net collections for hospital-based services, and pay for performance projects in the ambulatory settings. Analyze and report data related to case management activities, payer activities, resource utilization, and clinical denials. Lead hospital wide initiatives on behalf of the department. Define the role for care management by optimizing performance outcomes through readmission prevention, low acuity non-emergency (LANE) ED avoidance and reducing inpatient length of stay through comprehensive care planning that supports the highest level of symptom management in the home, school, community and/or ambulatory clinic.

Minimum Education
Master's Degree: Master of Nursing degree or equivalent (Required)

Minimum Work Experience
7 years Clinical nursing experience (Required) And
5 years Case Management related experience including care coordination, discharge planning, utilization review, clinical auditing, operational leadership, and financial/clinical data reporting. (Required)
3 years Some supervisory experience with executive level leadership (Preferred)

Required Skills/Knowledge
Facile with keyboarding and familiar with software such as Windows environment (i.e., Microsoft Office, Word, PowerPoint, Excel, Access).
Excellent written and verbal communication and presentation skills. Knowledge of children's health issues.
Knowledge of cultural issues and their impact on health care. Strong focus on Service Excellence and patient experience.
Working experience with medical management criteria such as MCG and/or InterQual.
Demonstrated success in managing day-to-day operations of case management and care coordination functions for a department and/or medical center that includes inpatient and ambulatory service lines.
Track record of meeting department goals without an adverse impact on employee morale or customer service
Ability to analyze and present productivity and outcome data using Microsoft Access and Excel.
Ability to plan, implement, and effect transformation from a "transaction" orientation to a high-quality customer service orientation which includes the physicians, patients, and community service providers as customers.
Knowledge of general business concepts including financial management and accounting principles and practice.
Ability to analyze and present complex financial, productivity and outcome data using software and data warehouse tools.
Experience with Cerner systems preferred.

Required Licenses and Certifications
Registered Nurse in District of Columbia (Required)

Basic Life Support for Healthcare Provider (BLS) (Required)
CCM or ACMA (certified case manager) (Preferred)

Job Functions
Resource Management

• Lead projects related to payer performance and work with Managed Care and others to address payer specific issues.

• Oversee human resource activities including selection and termination; training and staff; staff scheduling for coverage of all essential departmental functions, performance evaluation and remediation.

• Develop and enhance both staff performance and objective performance outcomes for all multidisciplinary staff.

• Update staff with relevant information from Children's National and CN-RSC via written communication, staff meetings and/or team huddles.

• Represent Care Management interests in organizational committees and leadership meetings.

• Collaboratively define staff workflows, workload, priorities, and resource allocation across the CN-RSC & Community Care Programs.

• Promote an environment that will support and recognize team and individual contributions.

• Identify potential billing compliance issues; assess enterprise risk; research resolutions; and work closely with Compliance

• Department to prioritize and correct potential issues.

• Work with Federal, State, and local authorities to review regulatory issues that affect submission and adjudication of claims.

• Reinforce organizational financial decision making processes with operational and financial data and information.

• Recognize and share incremental improvements in operations

Operations Management

• Supervise and evaluate the daily work of inpatient and ambulatory Case Managers, Social Workers and Community Health Coordinators in accordance with departmental and organizational policies.

• Assist with Case Management staffing schedule to ensure adequate coverage and optimize productivity. Assign coverage and deploy staffing accordingly.

• Function as a resource to staff and takes steps to resolve issues that arise internally and with payors. Collaborate with payers in the community programs.

• Work directly with payors to enhance communication and improve authorization processes.

• Assist with the management of High Risk cases and tracking.

• Participates in budget development and recommends budgets for areas of oversight

• Tracks referrals, referral sources & spending for areas of oversight

• Identify potential revenue (utilization) risk with Inpatient and Outpatient use; research resolutions; and work closely with clinical and/or financial departments to prioritize and implement corrective actions in the inpatient setting and community programs.

• Work with Federal, State, and local authorities to review regulatory issues that affect submission and adjudication of claims and payment for care management.

• Ability to assess all phases of the care continuum to identify opportunities for improvement; work with appropriate departments to resolve high risk patient issues; report findings and make recommendations to the Director of Integrated Care Management.

Education

• Provide education to the departments and the organization related to payor trends, denial activity and utilization/case management outcomes in addition to ambulatory program's LANE avoidance & readmissions to ED and/or hospital.

• Provide input and oversight to Shared Leadership's educational activities.

• Lead the development of educational programs for inpatient and ambulatory Case Management staff and their care teams.

• Provide hospital wide education on Care Management programs and initiatives with their outcomes.

• Implement the system for initial and ongoing staff development that includes competencies and continuing education programs.

Performance Improvement/Outcomes Management

• Ensure Case Managers, Community Health Coordinators & Social Work activities are in regulatory compliance (JC, CMS, DHCF)

• Track clinical, functional, operational, quality and financial data related to Clinical Resource Management

• Implement processes to continually improve performance, reduce denials, optimize reimbursement and care coordination

• Update departmental/team procedures to reflect changes in payor contracts, SCAs and departmental processes.

Organizational Accountabilities
Organizational Accountabilities (Managers)
Leadership Excellence

• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence is achieved

• Innovates through improvement of care and/or efficiency of operational processes.

• Dedicated to a standard of performance excellence and high quality

Collaboration

• Creates a safe environment that encourages brainstorming, creativity and "out-of-the-box" thinking

• Encourages a diverse group of people to communicate effectively and embrace creative thinking

• Drives the collaborative efforts of the team to achieve goals in the most effective and efficient way

• Demonstrates listening and feedback skills

Leadership Skills

• Proactively assumes responsibility and accountability for results to include management of organizational change

• Empowers staff in ensuring a culture of transparency, fairness, respect and excellence

• Strategically aligns operational and tactical objectives to drive business results.

• Encourages collaboration with team members based on trust, mutual respect, consistent visible support, and open and honest communication.

Supervisory Responsibilities
Blood Borne Pathogen Exposure
Protected Health Information Access Level
Working Environment
Physical Requirements
Travel Requirements