Works with specific patient populations, promotes the achievement of optimal clinical and resource utilization allocation, facilitates appropriate lengths of stay and reimbursement for all hospital admissions in accordance with goals and objectives. Acts as a key informational and educational resource liaison for care coordination team. Works to develop organizational approaches to problem solving for the management of patient stays in the acute setting and the transition to home or post-acute care. Analyzes current systems, data and variances to identify opportunities for improvement. Works to promote quality, efficient care through collaboration with l service lines, patients and families. This position is responsible for the management of complex cases, outliers, readmissions and transitions of care.
Essential Duties:
- Management for Improved Outcomes ◦ Oversees the management of specific patient populations across the continuum focusing on complex /high risk/ high cost/ and/or difficult placement patients. ◦ Manages cases with complex issues and outliers as identified by specific triggers and criteria from Care Coordination team ◦ Directs effective delivery of services with multidisciplinary team through patient care conferences. Collaborates with members of the team regarding the plan of care ◦ Serves as a resource to the entire care coordination team for the management of these patients ◦ Promotes timely interventions and multidisciplinary care conferences for specific patient populations ◦ Serve as patient & family advocate to achieve maximum patient satisfaction ◦ Manages activities associated with utilization management, care facilitation, discharge planning, denial management, DRG assurance facilitation. ◦ Facilitates learning experience of health care team members by formulating, implementing, and evaluating strategies for specialized staff education ◦ Works with physician leadership and interprofessional teams to develop clinical pathways and continuous care management programs ◦ Actively participates in clinical operational performance improvement and quality activities ◦ Identifies and plans strategies to reduce the length of stay and resource consumption. ◦ Works with health care team to develop measurement and feedback of performance indicators for cost, quality, service, and patient satisfaction ◦ Collaborates with care management team to assist with benefits and resource management for patients ◦ Assists with negotiation with payors and agencies to achieve re-certification or a more cost-effective alternative to care. ◦ Advocates for the patient and family maintaining availability to them as a resource to facilitate communication among providers ◦ Manages Transfer Back Agreements and Letters of Agreement related to inpatient transfers and placements.
- Utilization Management, Financial Management and Quality Screening for assigned patients: ◦ Applies approved utilization acuity criteria (such as Interqual) to monitor appropriateness of admissions and continued stays as the basis for managing identified outliers and complex case management. ◦ Communicates with Business Office, Patient Access Center, Physician Advisor and /or third-party payors to facilitate covered day reimbursement certification as needed and discusses payor criteria and issues on a case by case basis with clinical staff (i.e. Peer to Peer) and follows up to resolve problems with payors as needed. ◦ Collaborate for appropriate resource and financial management which may include but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, patient benefit coordination, assessment of working DRG and/or collaboration with Clinical Documentation Improvement team, assessment for appropriate usage of Health Care Resources/clinical cost efficiency. ◦ Educates hospital staff and physicians to the payor regulations to prevent denials. ◦ Analyzes clinical and resource data to identify areas where changes are needed related to clinical, financial, and satisfaction outcomes ◦ Collects and analyzes fiscal data, variance data, and outcome data relevant to target groups to promote quality improvement ◦ Serves as resource liaison for governmental regulations, and ethics/healthcare law. ◦ Complies with HIPPA and all privacy, safety, and confidentiality requirements and policies ◦ Acts as liaison to major customers including payors, outside resources, and third-party participants. ◦ Reviews denials, appeals, and avoidable days in order to develop improved processes ◦ Performs audits in conjunction with payor/hospital regulations ◦ Assists in responding to concurrent review/appeals and providing information as necessary to avoid denials for patient admission. ◦ Works with payers
- Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education: ◦ Collaborates with all members of the Interprofessional Team to identify and manage outliers. Monitors the patient’s progress, intervening as necessary for high-risk or difficult cases and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. ◦ Addresses/resolves system problems impeding diagnostic or treatment progress with the observation population proactively identifies and resolves delays and obstacles to discharge ◦ Provide education as needed to staff, physicians, and patients for transitional planning needs ◦ Collaborates and communicates with interprofessional team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation ◦ Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge ◦ Refers cases and issues to appropriate personnel, i.e. Medical Director, Physician Advisor or RN Senior Director, in compliance with department procedures and follows up as indicated ◦ Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues, involving RN Manager as necessary. ◦ Documents relevant discharge planning information in the medical record according to Department standards ◦ Works with post-acute providers and the Keck Medical Center Post-Acute Performance Network to identify issues and understand barriers to quality post-acute care ◦ Work with Patient Navigators to create a seamless experience for Keck Medical Center of USC patients.
- Clinical performance improvement, outcome management and quality activities: ◦ Uses data to drive decisions and plan/implement performance improvement strategies related to Clinical Care Coordination for assigned patients, including fiscal, clinical and patient satisfaction data ◦ Uses quality data to review readmissions identifying trends and working with teams to develop strategies to manage high risk groups. ◦ Collects delay for services and other Avoidable Day data for specific performance and/or outcome indicators and reports data through service lines and departments from the perspective of process improvement and quality outcomes. ◦ Participates in development, implementation, evaluation and revision of clinical pathways and other Clinical Care Coordination tools and serves as a member of the clinical resource/team, including participation of staff interviews/screening for hire. ◦ Educate the interprofessional team and physicians about clinical pathways/protocols and managed care principles ◦ Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiatives ◦ Identifies at-risk populations using approved screening tool and follows established reporting procedures ◦ Monitors clinical and financial indicators (i.e. length of stay (LOS), outliers, readmissions post-acute service destinations, avoidable days) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas as viewed on Care Management’s Dashboard
- Collaborates with Senior Director of Care Coordination and associated managers to: ◦ Assist with conducting staff meetings and role-based meetings ◦ Serves as mentor to staff ◦ Facilitates open communication ◦ Promotes team approach to working environment
- Other duties as assigned.
Required Qualifications:
- Req Bachelor’s degree Degree in Nursing (BSN); or Master of Social Work and LCSW or LSW certification
- Req 5 years Clinical hospital experience
- Req Deep knowledge of case management regulations, payor landscape and post-acute care transitions in California.
- Req Critical thinking skills and organization in prioritizing a workload of multiple tasks.
- Req Organization/time management skills.
- Req Excellent analytical, problem-solving, planning and evaluation skills.
- Req Commitment to continuous quality improvement and results driven outcomes.
- Req Requires knowledge of data entry into a database and the ability to analyze the information to improve care and outcomes.
Preferred Qualifications:
Required Licenses/Certifications:
- Req Registered Nurse – RN (CA Board of Registered Nursing) Or Current valid LCSW or LSW certification
- Req Certification – Job Relevant Current Accredited Case Manager Certification.
- 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 hourly rate range for this position is $53.00 – $87.45. 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.
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