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Nurse Clinical Resource Management Supervisor
1 month ago
The HSC Health Care System is a nonprofit organization combining the resources of a care coordination plan; (Health Services for Children with Special Needs, Inc.), pediatric specialty hospital (The HSC Pediatric Center), home health agency (HSC Home Care, LLC), and parent foundation (The HSC Foundation) to offer a comprehensive approach to caring, serving and empowering people with disabilities. The HSC team of 750 employees and more than 100 volunteers together serve children and young adults with special health care needs and their families at our District of Columbia and Maryland locations.
ESSENTIAL HSC MISSION AND VALUES
Mission Statement
HSC Health Care System provides and coordinates innovative, high quality, community-based care for individuals with complex needs and their families. HSC empowers all we serve to improve the quality of their lives.
Organizational Beliefs
HSC supports individuals and families to maximize their potential. The following beliefs drive our work. HSC believes that:
- A culturally diverse community is a strength.
- Inclusiveness for individuals, families, and staff promotes positive outcomes.
- Everyone should be treated with compassion and empathy.
- Our skillful, dedicated, and resourceful staff is key to our success.
- We must continually adapt to the changing needs of our community.
- Increased independence is an important goal for individuals and their families.
POSITION SUMMARY
The Supervisor, Clinical Resource Management is responsible for the leadership and day-to-day operations of the Collaborative Services team members at The HSC Pediatric Center. This position reports to the CN Director of Integrated Care Management with matrix reporting to the HSC Director of Patient Care Services. All nursing practice is based on the legal scope of practice, national and specialty nursing standards, HSCPC Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires registered professional nurses and social workers to be responsible and accountable for their own practice. HSCPC supports the development of RN relationships within the community; specifically, those relationships associated with the health and well-being of the community at large. Responsible for directing the activities of new patient referral intake, authorization and acceptance; patient care coordination, care progression and discharge planning; initial and continued stay clinical authorizations; inpatient denial mitigation and management; interdisciplinary high risk patient management; overall census and throughput management; and daily reporting to executive leadership at Children's National Hospital and The HSC Pediatric Center. Provides 24-hour accountability for these functions including weekend admissions and discharges.
Qualifications:
Minimum Education
Bachelor's Degree Health administration, social work, nursing, business administration or related discipline. (Required)
Master's Degree MSN, MBA, MSW, MHA or similar relevant advanced degree. (Preferred)
Minimum Work Experience
5 years Case Management related experience including discharge planning, utilization review, clinical auditing, and financial/clinical data reporting. Nursing Experience. (Required)
3 years Supervisory or managerial experience. (Preferred)
Required Licenses and Certifications
Registered Nurse (RN) license from the District of Columbia Upon Hire (Required)
Specialty Certification- CCM (Preferred)
Required Skills/Knowledge
- Knowledge of best practices as it relates to admissions processes, utilization review, discharge planning, case management, social work, care coordination and denial prevention and recovery methodologies.
- Knowledge of the principles of health care administration and health care finance; thorough knowledge of District and federal regulations and The Joint Commission regulations for hospitals and nursing homes.
- Knowledge of hospital risk management processes and performance improvement methodology
- Ability to develop and maintain effective working relationships with physicians, hospital managers, and other members of the interdisciplinary care team
- Ability to develop and maintain effective partnerships with referring hospitals, clinicians, and programs as well as public and private payers
- Ability to negotiate and execute single case agreements in collaboration with Managed Care and Revenue Cycle
- Strong communication skills both verbal and written
- Ability to organize, assemble, categorize and analyze clinical, financial and referral data to identify opportunities for growth and measure impact of expansion efforts
- Ability to plan and manage the work of others to achieve measurable clinical and financial outcomes
- Ability to effectively use complex computer applications including electronic medical records, portals, medical management programs, denial reporting programs, and referral management tools
- Working knowledge of industry standard medical management guidelines such as Interqual and MCG
- Sound professional judgment, dependability, tact, discretion, integrity, resourcefulness, accuracy and initiative.
Job Functions
Resource Management - Accountable to plan for staffing 24/7; continuously monitor and adjust staffing based on department needs.
- Support the Director with human resource activities of assigned team members including selection, input on performance evaluation, remediation & training.
- Accountable for assigned staff timecards and schedules in the Kronos system.
- Manage hiring of staff by conducting interviews and making recommendations for hire.
- Lead initiatives, projects, and committees aimed at clinical growth and margin improvement.
- Establish collaborative relationships and networks across the enterprise and the region to ensure effective patient outcomes and sustained patient volumes.
- Update staff with relevant organizational, community, case management, care coordination, and utilization information via written communication and staff meetings.
- Collaboratively define staff workflows, workload, priorities, and resource allocation across the enterprise
- Actively manage and report medical necessity denials to identify trends and specific issues that need action plans for resolution at the aggregate or individual level.
- Support systems that impact patient throughput, length of stay, utilization management & discharge planning.
- Lead recoveries of medical necessity-related appeals utilizing both internal and external resources, and implement process improvement to minimize final denials and avoidable days.
- Identifies and escalates denial trends; identifies internal and external causes and solutions.
- Facilitated the discussion and action plans around high-risk and long lengths of stay for patients to attain optimal clinical outcomes while mitigating negative financial impacts.
- Assess phases of the revenue cycle to identify opportunities for improvement; work with appropriate departments to address DNFB, authorization holds, work queues, clinical charge capture and denial mitigation.
- Works with Managed Care, Revenue Cycle, clinical care providers and others to address payer-specific issues.
- Identify potential billing compliance issues; assess enterprise risk; research resolutions; and work closely with Compliance Department to prioritize and correct potential issues.
- Work with Federal, State, and local authorities to review regulatory issues that affect the submission and adjudication of claims.
- Reinforce organizational financial decision-making processes with operational and financial data and information.
- Develop Effective Communication Channels with staff and patients/families
- Demonstrate advanced communication skills in dealing with staff, patient/family, and all members of the healthcare team.
- Provide constructive, sensitive, and timely feedback to staff concerning their performance in verbal and written form.
- Effectively manage conflict and assist others to understand their behavior and their effect on the work environment.
- Communicate and escalate clinical issues as appropriate to Director and MUD.
- May perform other duties in addition to those outlined in this job description
Organizational Accountabilities (Managers)
Leadership Excellence
- Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence is achieved
- Innovates through improvement of care and/or efficiency of operational processes.
- Dedicated to a standard of performance excellence and high quality
- Creates a safe environment that encourages brainstorming, creativity and "out-of-the-box" thinking
- Encourages a diverse group of people to communicate effectively and embrace creative thinking
- Drives the collaborative efforts of the team to achieve goals in the most effective and efficient way
- Demonstrates listening and feedback skills
- Proactively assumes responsibility and accountability for results to include management of organizational change
- Empowers staff in ensuring a culture of transparency, fairness, respect and excellence
- Strategically aligns operational and tactical objectives to drive business results.
- Encourages collaboration with team members based on trust, mutual respect, consistent visible support, and open and honest communication.
- The incumbent will be responsible for the general direction of staff member(s).
- Category II: Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens.
- Level IV - Full Access Incumbents in this job may access any protected health information associated to a customer's needs, the service(s) rendered and the position's functions.
- This job operates in a hospital or office environment.
- Light Work: Lifting 25 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.
- This is a full-time, regular position working standard and extended hours. Minimal travel required.
