Manager, Case Management/Utilization Review - Care Coordination Admin - Full Time 8 Hour Days (Exempt) (Non-Union)

The Case Management Manager provides administrative and operational support to the Senior Director. The Case Management Manager provides direct supervision to the RN Case Managers, Utilization Review Nurses and utilization review LVNs and ancillary staff, Transitional Care Coordinator, LVN Discharge Planning Coordinators and Discharge Planning Coordinators. The Manager provides support regarding difficult / complex cases. The Case Management Manager is accountable for daily department operations, including coordinating daily case management activities to conform to evidence-based practice and/or regulatory/payer requirements. This position integrates functions of case management, care coordination, utilization management, and discharge planning in collaboration with the SW Manager and staff. This position is responsible for daily department operations, including staffing, assignments, and human resources management. The Case Management Manager provides on call support for after hours, weekends, and holidays in coordination with the Senior Director.

Essential Duties:

• PEOPLE
• 1. Provides orientation and training for Case Management staff.
• 2. Participates in the hiring and selection of new staff.
• 3. Promotes positive partnership between Social Workers, Case Managers, Utilization Review nurses, Discharge Planning Coordinators and the multidisciplinary team in order to achieve coordinated, timely and patient-centered care.
• 4. Proficient in the use of computers and computer programs necessary to perform job responsibilities including Cerner, EnsoCare, InterQual.
• 5. Provides direct supervision for RN Case Managers, RN utilization management staff, LVN utilization management staff and ancillary staff, Transitional Care Coordinator, LVN Discharge Planning Coordinators and Discharge Planning Coordinators.
• 6. Partners with nursing leadership to educate nursing on case management process to minimize care/service delays and identify opportunities to improve throughput.
• 7. Works with Hospitalists, medical staff and Physician Advisors to ensure case management activities are integrated with the goals of physician partners.
• 8. Serves as facilitator of the Hospital Utilization Review Committee and serves on other Committees throughout the medical center.
• QUALITY
• 1. Conducts quality improvement activities including but not limited to audits, interrater reliability studies, and quality data collection.
• 2. Monitors InterQual reviews to ensure timeframes are met (24 hours for Admission InterQual and every Three days for Continued Stay InterQual.)
• 3. Ensures discharge planning assessments are performed within 24 hours to document ensure appropriate discharge planning activities throughout the patient’s hospital stay.
• 4. Ensures that departmental functions, policies and procedures and activities are in compliance with appropriate regulatory standards, including, but not limited to: Joint Commission, Federal, State, corporate compliance and other applicable professional codes.
• 5. Participates in the development and revision of appropriate department policies and procedures.
• 6. Assists with the development and monitoring of indictors for the department Quality Dashboard to ensure department goals and quality processes are effective.
• SERVICES
• 1. Participates in Interdisciplinary meetings and care coordination rounds. Demonstrates knowledge of patient’s clinical condition, care coordination, and discharge planning status.
• 2. Works with admissions case manager to effectively screen unscheduled/urgent admissions.
• 3. Provides supervision for case management staff in absence of the Senior Director to ensure department operations run efficiently.
• 4. Conducts staff evaluations and competency testing to ensure quality of department services.
• 5. Provides on call coverage for department coverage after hours, weekends, and holidays as designated by director.
• 6. Reviews Important Message from Medicare data to ensure notices are issued per the requirements’.
• 7. Works with the Quality Improvement Organization when patients / families appeal discharges. Maintains records of appeals and outcomes.
• COST
• 1. Provides coverage for Case Management staff for scheduled and unscheduled absences such as vacations or sick time or during high volume workdays.
• 2. Participates in utilization management activities to ensure hospital resources are utilized appropriately.
• 3. Participates in the denial appeals process to identify opportunities to improve denial rates.
• 4. Responsible for daily staffing and assignments to optimize department services.
• 5. Ensures case management staff provide appropriate phone and/or fax reviews to managed care providers timely.
• 6. Assists with data collection and audits to maximize potential reimbursement and minimize financial risk (Medicare One Day Stay).
• GROWTH
• 1. Provides consultations to Case Managers on difficult cases and provides a second opinion, expertise, and problem-solving assistance.
• 2. Contributes to self development by attending seminars and educational classes.
• 3. Demonstrates the ability to effectively train department staff on use of laptops and computer programs.
• 4. Assists with identification of staff educational needs and develops appropriate in services education.
• 5. Other duties as requested or assigned.

Required Qualifications:

• Req Bachelor's degree Graduate of an accredited school of registered nursing. Bachelor’s Degree in Nursing (BSN)

• Req 3 years 3 - 5 years clinical experience.
• Req 5 years Experience in hospital-based case management.
• Req 2 years Consecutive years’ experience in case management leadership at the Manager level.

• Req Ability to work independently with minimal supervision, exercising judgment and initiative.
• Req Ability to perform a variety of complex analytical and administrative duties and manage conceptual assignments.
• Req Knowledgeable regarding use of computer-based applications.

Preferred Qualifications:

• Pref Master's degree Master’s Degree in Nursing (MSN).
• Pref Specialized/technical training Accredited Case Manager.

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

The annual base salary range for this position is $121,680.00 - $270,772.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.