Director of Case Management

Job Title: Director of Case Management, Inpatient Prospective Payment System, and Utilization Review

Department: MFB at Schwab - Chicago, IL

Reporting Relationship: President, Schwab Rehabilitation Hospital

Mary Free Bed Summary

We have the great privilege of helping patients and families re-build their lives. It’s extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients “Ask for Mary,” they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them. This is true of every employee, from support staff and leadership, to clinicians and care providers.

Mary Free Bed is a not-for-profit, nationally accredited rehabilitation hospital serving thousands of children and adults each year through inpatient, outpatient, sub-acute rehabilitation, orthotics and prosthetics and home and community programs. With the most comprehensive rehabilitation services in the Midwest and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. The growing Mary Free Bed Network provides patients throughout the Midwest with access to our unique standard of care

Mission Statement

Restoring hope and freedom through rehabilitation.

Employment Value Proposition

At Mary Free Bed, we take pride in our values-based culture:

· Diversity, Equity, and Inclusion. Our Commitment to providing an inclusive environment for patients, families, staff, and community, through embracing Diversity, Equity, and Inclusion T.O.G.E.T.H.E.R.

· Focus on Patient Care. A selfless drive to serve and heal connects all MFB employees.

· Clinical Variety and Challenge. An inter-disciplinary approach and a top team of professionals create ever-changing opportunities and activities.

· Family Culture. We offer the stability of a large organization while nurturing the family/team atmosphere of a small organization.

· Trust in Each Other. Each employee knows that co-workers can be trusted to make the right decision for our family, patients, staff, and community.

· A Proud Tradition. Years of dedicated, quality service to our patients and community have yielded a reputation that fills our employees with pride.

Summary

Responsible for the overall management and effective operations of the care management team, prospective payment system, and utlization review.

Care Management: responsible for providing and/or overseeing high quality care management and patient transition services that promote optimal functioning throughout the rehabilitation process for all patients and families. Specifically, this leader is responsible for the following:

· Facilitate coordination of care between care managers, nursing, therapy and medical services to ensure that quality care is provided for all patients.

· Serve as “Program Champion” for Care Management as part of an overall plan for census growth and stability for all assigned programs/populations.

· Use monitoring and measurement tools to ensure effectiveness in all service areas according to defined parameters.

· Ensure that patient satisfaction targets, regulatory compliance requirements, documentation standards, and certification requirements are met.

Prospective Payment System: Coordinates the completion, review and timely transmission of the IRF-PAI for acute rehabilitation units. Performs QA activities and ensures regulatory compliance.

Utilization Review: Coordinates and implements the facility’s Utilization Review process and performs activities to validate the medical necessity and length of patient stay.

Essential Job Responsibilities

o Care Management

o Assure that appropriate safety and clinical standards of care are met for care management in accordance with all applicable regulatory accreditation (CMS, applicable state licensing departments, CARF, The Joint Commission, etc.) requirements, hospital policies and procedures and industry standards for clinical practice.

o Collaborate with the Director(s) of Rehabilitation, Medical Directors, hospital staff and physicians to serve as point of contact for clinical information, problem-solving and networking for all assigned programs/populations.

o Responsible for assuring appropriate staffing levels, equipment, and supplies to meet patient care manager needs.

o Effectively manage clinical/medical resources with the interdisciplinary team, such as: service intensity, length of stay, care manager productivity and service frequency in order to achieve optimal results.

o Monitor clinical documentation to ensure full regulatory compliance.

o Provide leadership to remain in continuous readiness for The Joint Commission and CARF surveys if applicable.

IRF-PAI Responsibilities

o Directs and manages staff to ensure the timely and accurate completion of the IRF-PAI. Makes corrections in the process and procedure of IRF-PAI completion as appropriate.

o Ensures the timely completion and submission of patient data for payment. Ensures patient data is accurate and provided in a timely manner for reporting and benchmarking purposes.

o Ensures the timely and accurate entry of billing information into BAR.

o Maintains knowledge of regulatory rules and requirements pertaining to IRF-PPS. Recommends revisions to process and/or procedures as required.

o Provides education and training to staff, physicians and management with regard to IR-PPS regulatory requirements

o Facilitates and coordinates medical staff compliance with CMS requirements. Communicates CMS regulatory requirements to staff as required.

o Interacts and communicates with Medical Records Department, Physicians and others to ensure the accuracy of information included on the IRF-PAI such as co-morbidities and medical diagnosis.

o Recommends, implements and ensures the effectiveness of process improvements based upon outcomes to enhance the overall efficiency and effectiveness for implementation of IRF-PPS.

o Participates in various staff conferences, projects and committees to facilitate and enhance the quality of patient care.

Utilization Review Responsibilities

o Implements the utilization review process for acute rehabilitation

o Confers and communicates with physicians, therapists and nursing staff to obtain clinical updates which support the admission and continued stay criteria.

o Serves as a resource and coordinates requests for clinical information to assist in the payment appeal process.

o Maintains payer denial log. Analyzes denial log to identify discrepancies in denials.

o Coordinates all Medicare Discharge Notice Appeals.

o Co-chairs Utilization Review Committee and ensure that issues receive appropriate follow-up at subsequent meetings.

o Collaborates with medical staff to develop and revise the Utilization Review Plan and monitors for compliance.

o Conducts chart reviews and collaborates with the healthcare team to facilitate documentation within the medical record that supports the medical necessity of continued stay and meets regulatory requirements.

o Performs concurrent, retro and continued stay charts audits using appropriate criteria.

o Performs concurrent, retro and continued stay charts audits using appropriate criteria.

o Acts a resource, and subject matter expert, on utilization issues for physicians, staff and others in the organization.

Fiscal Responsibility

o Responsible for the development of, and operation to, the annual budget for assigned programs.

o Monitors and assures achievement of at least minimum clinical productivity requirements.

o Analyzes IRF-PAI, UDS, FIM, CMG, RIC data to identify opportunities for clinical and financial improvements

Interdisciplinary Care Model

o Ensure collaborative interdisciplinary team model that demonstrates a culture of team work, personal accountability, solution-seeking behavior, mutual respect, open communication, openness to change, enthusiasm, and pride, consistent with the Relationship-Based Care model.

o Promote collaboration among disciplines, departments, and Network members.

o Maintain effective working relationships with program medical directors and admitting physicians.

o Facilitate interdisciplinary team conferences by directing the team’s focus on assessing the patient’s progress toward goals; removing barriers that impede progress toward goals or

discharge; reassessing the validity of the rehab goals previously established; monitoring and revising the treatment plan as needed; efficient use of healthcare resources, including efficient reporting processes.

Staff Management and Development Responsibilities

o Responsible for the management of staff including the selection, training, motivation, development, evaluation, rewarding and, when required, termination.

o Ensures that performance evaluations are conducted in a timely manner. Recommends adjustments to base pay as appropriate.

o Creates a positive and supportive work environment and demonstrates excellent customer service in all interactions.

o Directs staff in maintaining confidential patient information required to protect patients, physicians and the hospital.

o Conducts monthly staff meetings to communicate relevant departmental information and obtain concerns of staff.

o Develops a system for defining and monitoring departmental performance indicators.

o Demonstrates computer input expertise including the ability to navigate and find information in the Meditech system and other computer systems required for utilization review, PPS and outcome data.

o Maintains clinical competencies.

o Responsible for providing input into the annual capital and operating budgets for assigned departments.

o Assists with ongoing survey readiness and regulatory compliance.

o Participates on various hospital committees and task forces as assigned.

o Completes work assignments in a timely, efficient and cost effective manner. Prioritizes tasks appropriately.

o Takes initiative to maintain a high level of productivity. Anticipates the needs of co-workers and the department.

o Functions as a team player and contributes to team goals. Maintains flexibility in assisting to meet departmental and hospital needs. Contributes to identification and resolution of departmental and hospital issues.

o Communicates effectively following designated chain of command. Reports pertinent issues promptly to appropriate staff. Seeks clarification when expectations are unclear.

o Completes all certification and/or credentialing as required.

o Performs other related duties as assigned/required.

Leadership Must-Haves will be followed for patient and staff interactions:

· Embrace Diversity, Equity and Inclusion, by:

Treating everyone with dignity and respect

Opening more doors to opportunities for underrepresented cultures

Growing talent and people

Evaluating and eliminating disparities

Taking action against injustices, bias and racism

Honoring our differences and how to collaborate

Educating staff, patients and the communities we care for

Restoring Hope and Freedom, together

o Rounding

o Thank You Notes

o Employee Selection/Peer Interviewing

o Key Words at Key Times

o AIDET® + Promise

o Standards of Behavior

Customer Service Responsibilities

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.

Responsibilities in Quality Improvement

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.

Essential Job Qualifications

· Bachelor Degree in Nursing, Occupational Therapy, Physical Therapy, Speech Language Therapy, or Social Work from an accredited program

· Minimum four (4) to five (5) years experience in related field.

· Previous experience in Inpatient Rehabilitation Setting

· Previous experience in case management and/or utilization review

· Previous experience in IRF-PPS application, previous management experience preferrred

· Knowledge of ICD-9 coding, previous work experience preferred.

· Ability to function as a resource and subject matter expert to staff and demonstrate ability to educate regarding IRF-PPS regulatory and compliance matters.

· Knowledge of health insurance authorization and appeal process and procedures.

· Excellent writing, verbal and interpersonal communication skills.

· Knowledge of relevant local, state and federal rules and regulations.

· Knowledge of basic computer software applications such as MS Word, Excel, Access and Powerpoint; database applications and other PC-based applications.

Physical Requirements for Essential Job Qualification

Levels:

· None (No specific requirements)

· Occasionally (Less than 1/3)

· Frequently (1/3 to 2/3)

· Majority (More than 2/3)

Remain in a stationary position: Majority

Traverse or move around work location: Occasionally

Use keyboard: Frequently

Operate or use department specific equipment: None

Ascend/Descend equipment or ladder: None

Position self to accomplish the Essential Functions of the role: Frequently

Receive and communicate information and ideas for understanding: Majority

Transport, position, and/or exert force:

Up to 10 pounds: Occasionally

Up to 25 pounds: Occasionally

Up to 50 pounds: None

Up to 75 pounds: None

More than 100 pounds: None

The above statements are intended to describe the general nature and level of work being performed by employees in this classification. If you require a reasonable accommodation to perform the essential functions of this position, you must request accommodation in writing, within 182 days after you know or should know of the need for accommodation.

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.

MFBNUIJ

Location: Mary Free Bed Rehabilitation Hospital · MFB at Schwab
Schedule: Full-Time, Days, 8am-5pm