RESPONSIBILITIES:
1 Monitors performance in assessing the quality, safety, and appropriateness of each assigned patient’s care/service according to the standards approved in the UR Plan of the Medical Staff.
2 Serves as an expert resource in teaching and monitoring care managers in the use of InterQual Criteria.
3 Monitors the documentation of all components of patient assessments, reassessments, and interventions for conciseness, accuracy, timeliness and compliance.
4 Monitors care managers’ involvement in the development of plans of care that are patient focused; promoting patient/family/significant other involvement and choice.
5 Monitors care managers knowledge and promotion of use of evidence-based practices for the patient populations managed.
6 Serves as an expert resource to the interdisciplinary team in correctly interpreting current regulatory, accrediting and third-party payer standards related to care management functions.
7 Monitors care managers’ involvement in the development of plans of care that are continuum-based; maintaining strong working relationships with other transitional levels of care within the community and surrounding areas.
8 Monitors the care managers’ involvement of the physician advisor for in-depth clinical education and to facilitate effective communication and problem-solving with attending physicians.
9 Monitors the care managers’ involvement of the physician advisor for in-depth clinical education and to facilitate effective communication and problem-solving with attending physicians.
10 Demonstrates effective interpersonal skills when communicating with patients/families/significant others, members of the interdisciplinary team, and third-party payor
representatives.
11 Demonstrates ongoing prioritization of care management activities throughout the shift with the care management team in order to meet patients’ needs and expectations.
12 Promotes problem-resolution and decision-making at the lowest possible level and follows the designated chain of command when consensus and/or compliance are not achieved.
13 Monitors care managers’ interventions in facilitating timely completion of diagnostics and treatment.
14 Through interface with third party payors and care managers monitors the timeliness and accuracy of information provided to third party payors for compliance with contractual agreements.  With input from care coordinators manages the timeliness and accuracy of reviews and appeals for denied cases.
15 Monitors care managers’ collaboration with the interdisciplinary team in continuously evaluating plans of care and treatment and making pertinent recommendations for revisions when indicated.
16 Monitors care managers’ constructive reporting of issues to the interdisciplinary team using the SBAR format; ensuring that recommendations are realistic, in keeping with standards, and reflect patient/family/significant other input and choice.
17 Manages the peer review activities of the care managers in continuously striving for the highest standards of practice.
18 Demonstrates the ability to teach adults with varied backgrounds and learning styles and achieve positive feedback/actions reflecting their comprehension.
19 Demonstrates expertise in analyzing care management data and managing departmental quality assurance and performance improvement activities, as well as effectively participating in interdepartmental and Medical Center wide teams.
20 Manages the recruitment; interviewing; hiring; performance monitoring, evaluation and disciplinary action when indicated for all staff in the department
21 Manages the development, implementation and monitoring of the department budget; providing monthly reconciliation and variance reporting to the Director.

QUALIFICATIONS/JOB REQUIREMENTS:
EDUCATION:
CERTIFICATIONS/LICENSURE:
 Current California Registered Nurse License in good standing
 Current BLS certification by the American Heart Association
 ACM certification preferred

QUALIFICATIONS/JOB REQUIREMENTS AND EXPERIENCE:
 A minimum of 3 years acute care hospital nursing experience preferred.
 Previous case management experience in an acute care setting preferred.
 Working knowledge of current clinical, regulatory, accrediting, and third-party payor standards (i.e. Medicare, MediCal, and other Third-Party Payor regulations).
 Proficiency in InterQual Criteria.
 Effective and efficient communication skills (written, verbal, and/or computerized). Must be able to use verbal, non-verbal and written communication skills which reflect nursing standards.
 Knowledge of current utilization/quality management principles, techniques and procedures to include proficiency with hospital applications such as SoftMed, InterQual, all Microsoft applications.
 Ability to work as an effective member of an interdisciplinary care team as a consensus builder.
 Ability to work independently with minimal supervision; assuming professional responsibility and accountability for all actions.
 Strong organizational and time management skills.
 Demonstrates knowledge of proper documentation.
 Excellent written and verbal communication skills
 Proficient with computer systems including but not limited to MS Office