Manager, Case Management

Title: Manager- Case Management

Location: Fountain Valley

Department: Inpatient/Specialty Services

Status: Full-time

Shift: Day

Pay Range*:  $126,484.80 - $189,716.80/annually

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

Position Summary

Under minimal supervision and in a professional and friendly manner, this position has responsibility for the day to day clinical operations of the Case Management-Inpatient Services within the Medical Management department.The position requires working with the aligned Medical Directors, Director of Medical Management and other identified leadership to achieve the overall strategic goals of the department as they relate to the clinical care rendered by providers to patients within MemorialCare Medical Foundation and in adherence to any compliance and regulatory requirements  

Essential Functions and Responsibilities of the Job

1. Effectively manage the day to day operations of assigned area by applying advanced critical thinking, effective employee engagement strategies and lean principles to:
1. Case Management- Inpatient Services (On site and/or Telephonic at Acute, Skilled Nursing Facilities and Transition of Care)
2. Develop workflows, policies and procedures to ensure and maintain Medical Management contracts, provider contracts, DOFR, Health Plan delegation contract requirements and all regulatory requirements are met.
3. Operational oversight to all aspects of Inpatient staff within assigned area including:
1. Selection, orientation, training, coaching, attendance, payroll, performance (real time and annual) of staff.
2. Along with the department Director actively involved with department budgetary process within each fiscal year including planning and monthly oversight to potential and real variances. Timely communication to reporting manager and corrective action to ensure future budget alignment.
3. Support overall employee engagement strategies within teams and via Supervisors that align with the organizations positive impact on overall outcomes and achieve performance quartile as set forth via department and/or organization.
4. Develop, maintain and revise Lean Management Tools including; Visual Management Systems, Huddles and PDSA activities with Supervisors and Staff on a regular basis and that align to unit and department strategic goals and initiatives.
5. Actively identify, and report trends and variances to goals by engaging with Medical Directors, Hospitalists, Staff and other relevant department leadership and staff to efficiently and effectively develop corrective action activities that can positively influence outcomes.
6. Complete all required reporting to department leads in an accurate and timely fashion.
4. Oversite and coaching to team Supervisors, as applicable including: Coaching and Performance along with frequent interactions that support the functions and activities for which they have director supervision to and to ensure quality and outcomes.

5. Support and complete all daily and after-hours staffing assignments, along with team supervisors for adequate inpatient workflow.Timely reporting to Manager and/or department head, any potential or real staffing needs with appropriate documentation to support.
6. Ensure all staff in assigned area of activity perform daily functions and activities per policies and procedures and workflows for Inpatient (Acute, SNF and Care Transitions).

I. Activities include:

1. Evaluate and monitor patients for inappropriate admissions, appropriate level of care and length of stay Apply MCG, goal length of stay or other applicable evidence-based guidelines tools including; MCG and Inter Qual. Assist in maintaining inpatient metrics set by MCMF Medical Management.
2. Document admission, bed day, readmission, issue variances or denials when applicable with focus to root cause analysis.
3. Issue Important Message from Medicare and Detailed Notice of Discharge per regulatory guidelines if notified of an appeal.
4. Provide Hospital staff with contracted providers per health plan contracts.
5. Always Collaborate with Hospital staff and leadership to ensure positive relations.
6. Meet with patient and/or family at bedside as needed.Make follow up appointments with PCP and Discharge Clinic as applicable
7. Evaluate and supervise a discharge plan for each member assigned.Process discharge orders per criteria, benefits and eligibility
8. Determine patient level of acuity and refer to appropriate post discharge services/program including, Case Management as indicated
9. Participate in daily inpatient rounds, huddles, team meetings webinars, training and any other meetings as directed by leadership team.
10. Repatriate patients whenever possible if admitted to out of network facilities.Assist health plan repatriate out-of-area patients by providing Hospital Bed Board and Hospitalist phone numbers. Ensure that patients are followed by assigned/contracted Hospitalist and contracted Specialists
11. Submit letter of agreement for non-contracted physicians to contracting department when indicated
12. Understand DOFR’s (division of financial responsibility) as it relates to the inpatient process

*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Minimum Requirements

Qualifications/Work Experience:

•  Minimum three years of previous Manager role in Health Care related position
• Strong Inpatient, Managed Care and Population Health background
• Exceptional verbal, written and critical thinking skills
• Proficiency in Microsoft Word suite, Electronic UM/CM Medical Records platform (Epic, Next Gen, Sunrise or like) and other Analytic tools  (ex- Health Catalyst)
• Work experience applying evidence-based criteria (i.e.: MCG, lnterqual); Health plan medical policy / clinical coverage guidelines.
• Knowledge of CMS (Centers for Medicare and Medicaid Services) coverage policies required.
• Inpatient nursing or related field

Education/Licensure/Certification:

• Current California Registered Nurse license (RN)
• Bachelor of Science in Nursing or related field
• Active BLS (CPR)
• CCM preferred.