Assistant Director of Case Management and Utilization Review - RUHS - Medical Center

• Assist in directing, planning, developing, and evaluating the case management and utilization review activities related to safe, timely, efficient, and effective discharge planning within all areas of RUHS. 

• Develop standards for case management and utilization review, policies and procedures to guide medical and nursing staff regarding referrals, medical necessity, admission/discharge/ transfer process, and other utilization management activities; develop performance improvement plans; monitor quality indicators for care coordination, utilization review, and discharge planning.

• Collaborate with physicians and nursing managers to develop and implement case management/utilization review plans in compliance with federal and state laws and regulations, and with accrediting agencies. 

• Ensure staff and processes are maintained for appropriateness of admissions and inter-institutional transfers with related fiscal approvals for reimbursement or applications for emergency Medi-Cal; ensure access to social services support for patients and their families.

• Assist in designing, recommending, and initiating cost-effective approaches to discharge planning to reduce length of stay and to optimize quality outcomes that balance utilization management and fiscal reimbursement; develop and implement action plans to optimize hospital reimbursement in collaboration with related departments.

• Administer general personnel management matters and actions; resolve problems involving grievances and discipline.

• Supervise, recruit, select, assign, orient, and evaluate performance of staff; assess staff competency, especially in performing clinical procedures; assess developmental needs of staff and provide training opportunities; counsel staff on performance expectations and discrepancies.

• May participate in RUHS committees and processes focused on decreasing hospital length of stay and increasing efficiency.

• Assist in strategic planning for the organization and align departmental goals and objectives with the mission, vision, and values of the organization.

• May participate in local and national organizations to represent RUHS.

• Maintain daily work assignments and attendance records.

• May assist in the preparation of budgets for assigned areas and integrate with organizational budgets.

• Maintain records and present oral and written reports.

• Investigate complaints regarding patient care and staff.

OPTION I
Education: Graduation from an accredited college or university with an Associate's degree in nursing. A Bachelor's degree in nursing is preferred.

Experience: Three years of charge nurse or supervisory experience working as a registered nurse in an accredited acute care hospital. Professional experience in case management and utilization review in a hospital is preferred.
 
Knowledge of: Principles and practices of nursing and patient care services for case management, discharge planning, utilization review, social work, and quality improvement related to care coordination across the continuum of care in an acute healthcare organization; Joint Commission, state and federal laws and regulations related to case management and reimbursements; InterQual clinical criteria system; principles and techniques of effective supervision, management, and administration.

Ability to: Clearly and effectively communicate verbally and in writing with staff and the public; plan, organize, direct, coordinate, and review the activities of operating room/perioperative nursing services; supervise, instruct, motivate, monitor, train, and evaluate professional and nonprofessional employees; recommend improvements in nursing operations consistent with current nursing trends; establish and maintain systems of records and reports; establish and maintain cooperative relationships with staff and the public.
 
OPTION II
Education: Possession of a Master's of Social Work degree, preferably with specialization in medical social work, from a recognized school of social work.

Experience: Two years as a medical social worker in a hospital or healthcare clinic or agency.

Knowledge of: Principles of effective management; medical social casework principles and practices; psychological aspects of physical and emotional disturbances and mental deficiencies; characteristics of emotional and mental disorders including their effect on the individual in the community; mental health local community resources and community support systems; laws, regulations and policies standards of Joint Commission, federal, and state regulatory agencies; techniques used in providing casework consultation to staff.

Ability to: Plan, organize and direct the social services of a hospital or health system; interpret regulatory agency policies and guidelines; organize County and community resources and contract providers to service the community and achieve program goals; define problems and develop and implement solutions; establish and maintain effective working relationships with other agencies, community organizations and other hospital or health system divisions; prepare clear and concise reports.