Responsible for improving the quality and continuity of patient care at the hospital and in the home, controlling resource utilization, and achieving EOGH length of stay objectives through the establishment and management of a discharge planning program which encompasses social services home care coordination, and utilization review. The Director of Case Management reports directly to the Chief Nursing Officer.
Provides leadership in the development, direction and evaluation of an effective regional utilization management program that supports the delivery of high quality health care in the most appropriate and cost-effective manner. Provides consultation and support for health plan and medical group utilization review activities that influence medical and clinical outcomes.
Provides leadership in ensuring appropriate mechanisms and systems are in place to ensure the smooth integration of member care between hospitals, sub-acute, skilled nursing, ambulatory and home care. Builds effective partnerships with other leaders and functions to ensure integration occurs. Represents the organization in operational relationships with hospitals, skilled nursing or rehab facilities, as well as with other network providers/practitioners.
Partners with regional and service area leadership as well as health care teams to ensure that required internal systems and processes to manage the high risk, high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis.
Assures development and implementation of hospital discharge management to ensure the effective, appropriate and integrated management of high risk, high cost and medically complex patients. Ensures the support, training, evaluation and reporting mechanisms are in place to meet local and national markets as well as employer groups and regulatory/ accrediting agencies needs and requirements.
Develops systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes.
Provides leadership and consultation to physicians, service chiefs, other providers/practitioners and clinical personnel in the use of clinical measurement data for utilization management system improvements and redeployment of resources. Data will be used to review outcomes and continually improve health status outcomes.
Represents the region in utilization management in all regulatory, licensing and legislative arenas, such as NCQA, CMS, State or other employer requirements. Prepares and presents information and testimony to ensure compliance with medical guidelines and procedures required by both KP internally and/or outside accredited agencies.
Accountable for the administrative leadership and budgetary responsibility for the team of staff that support these functions in the department. Ensures that their functions are aligned with and supportive of the overall operational leadership goals.
Ensures the quality oversight of contracted and internal services in the continuum of care.
Minimum 8 years of previous experience either in acute care or ambulatory environment required
Minimum 5 years of Managed Care background and experience in increasingly complex health care management roles with relevant experience in utilization management required.
RN with BA degree, MA degree preferred
Current NJ State R.N. License
Any AACC, CCM, or CPUR is preferred, minimum of 3 years Case Management and Supervisory experience
Experience with multiple sites of care, i.e. acute, ambulatory, home health, subacute, rehab, long term acute, hospice, palliative care or skilled nursing facilities.
East Orange General Hospital has been a trusted heath resource for generations of families in the Newark area. Each employee at EOGH is an integral part of our organization and plays an important role in helping to fulfill our Mission. As an employee of East Orange General Hospital (EOGH) you would become part of a highly skilled, dedicated and caring healthcare team committed to providing high quality service and exceptional patient care to meet our community’s healthcare needs. At EOGH you will have the opportunity to learn and grow in a supportive and exciting work environment, thereby enhancing your career goals and aspirations.
EOGH offers an extremely varied and comprehensive benefits package which includes health, dental, prescription and vision care, life & disability insurances, tuition assistance, employee wellness & assistance programs, generous paid time off, retirement plan, medical library services, free & secure parking, low cost meals and many consumer discount programs and activities.
Apply online at https://pm.healthcaresource.com/cs/eogh#/job/304 or email resume to LyteJ@eogh.org