Job Summary

This role manages the day to day operations of the Cross Care Continuum teams who provide care navigation, care coordination, utilization management, discharge planning, and denials prevention. The Manager is accountable to ensure continuity in service delivery to patients receiving acute care services. The Manager is responsible for budget functions including forecasting resource needs for the assigned cost center(s), creating and implementing annual staffing and operations budgets, and recommending capital needs. The manager selects, hires, develops, supervises and evaluates the professional care management staff of RN’s and Social Workers and unlicensed support staff. Leads clinical initiatives to achieve clinical and financial metrics. Contributes constructively to the clinical, quality, financial and patient engagement outcomes of the health system. Works collaboratively with peer-leaders, physicians, and other professional colleagues to achieve positive outcomes and to ensure compliance with regulatory and accreditation requirements. 

Responsibilities and Essential Functions

• Provides managerial oversight to a diverse staff, including RN care/case managers, medical social workers, and other support personnel, facilitating patient care coordination within acute care services. Maintains optimal staffing levels to execute designated care management and utilization management strategies for hospitalized patients, ensuring consistency and continuity in assignments. Collaborates with recruitment professionals to hire qualified candidates, oversees comprehensive onboarding and ongoing education, evaluates performance, and upholds adherence to national care management standards. (50%)
• Collaborates with physician and administrative leaders to ensure completion of requested peer-to-peer clinical payer reviews; keeps team informed of NorthShore care management program performance results (5%)
• Uses data (length of stay, observation status management, time of discharge, discharge destination, denials, appeals, etc.) to drive improvement in patient care management and utilization of health system resources. Regularly shares performance data with staff in order to engage them in improvement activities. (10%)
• Provides consistent communication to staff in an atmosphere of openness that welcomes participation; conducts departmental staff meetings at least monthly. (5%)
• Promotes a positive practice environment that encourages professional growth and accountability. (5%)
• Provides staff support to health system committees; presents data, analysis/interpretation, and recommendations in a concise, coherent manner to appropriate audiences, to include, but not limited to the Utilization Management Committee. (5%)
• Leads and/or participates in improvement activities within the department and more broadly across the organization to promote continuous improvement in clinical and operational outcomes. (5%)
• Independently problem solves operational issues in the department in order to foster positive employee engagement. Keeps other leaders, and departments informed of changes as they occur. (10%)
• Works continuously to achieve “top box” patient engagement results for the department and organization. (10%)

Qualifications: Models behaviors and organizational standards to promote quality, patient safety, and enhanced patient care coordination. Serves as role model for professional commitment, professional behavior and effective problem-solving. Serves as a resource for staff on complex cases/situations. Serves as a resource for interpretation of regulatory requirements and assures department and personnel practices are consistent with law, regulation, policy and professional standards. Expert current knowledge of case management standards of practice in health systems (ACMA or CMSA). Maintains active membership in professional organizations (ACMA, CMSA, AONL).

Minimum Education Level Bachelor’s Degree in a healthcare related field (Nursing/Social Work/Therapy) required. Master’s degree preferred

Minimum Licensure Requirements Active, unencumbered license to practice in clinical discipline of Nursing/Social Work/Therapy required.

Minimum Certification Requirements

Certified case management ACMA or CMSA preferred

Minimum Work Experience

• Minimum five years of quality management/care coordination/health care experience in a hospital setting
• Minimum three years of management and/or leadership experience

Knowledge, Skills and Abilities (KSAs) [Optional]

• Knowledge: Information needed by an individual to do the job
• Skills: Measurable capability to complete a certain task
• Abilities: Describes proficiency in a particular area

Working Conditions

Working conditions are those of a general office environment

Technical Skills [Optional]

• Previous case management and/or utilization review experience in an inpatient or payer-based setting.
• Expert user of word processing, presentation and spreadsheet programs; familiarity with and ability to successfully navigate electronic medical records; familiarity with MCG and/or Interqual criteria and systems support.

• Expert verbal and written communication skills.
• Knowledge of community resources for patient care management.

Scope: People Management

Generally responsible for the day to day management of a team of up to 30 individuals.