Director, Utilization Review and Social Worker Services Exempt

CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care.

With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.

HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous research centers in the U.S. and Korea including a medical university, and CHAUM (a premier anti-aging life center).

Major Responsibilities/Essential Functions

Position Summary

The individual in this position has overall responsibility for hospital utilization management, transition management and operational management of the Case Management Department in order to promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with all state and federal regulations related to case management services.

Duties

This position integrates national standards for case management scope of services including:

• Utilization Management supporting medical necessity and denial prevention.
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction.
• Care Coordination by demonstrating throughput efficiency while assuring care in the right sequence and at appropriate level of care.
• Compliance with state and federal regulatory requirements, TJC accreditation standards and HPMC Policy.
• Education provided to physicians, patients, families and caregivers.
• Manage department operations to assure effective throughput and reimbursement for services provided.
• Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement.
• Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and HPMC policy.
• Ensure timely and effective patient transition and planning to support efficient patient throughput.
• Implement and monitor processes to prevent payer disputes.
• Develop and provide physician education and feedback on hospital utilization.
• Participate in management of post-acute provider network.
• Ensure compliance with state and federal regulations and TJC accreditation standards.
• Utilizes available community, government, and/or client resources needed to address participant's limitations or support interventions in the management of the participant's chronic condition.
• Manages behavioral and psychosocial needs that result in improved clinical and financial outcomes and delivers social work interventions.
• Assists members to effectively utilize available resources to meet their personal health needs and help them develop their own capabilities.
• Evaluates members' ability to independently manage self and locate alternative resources when limitations are identified via a Social Work Psychosocial evaluation.
• Provides guidance to members seeking alternative solutions to specific social, cultural or financial problems that impact their ability to manage their healthcare needs.
• Evaluates members' strengths related to health self-management, develops strategies to support healthcare needs and implements plans in support of case decisions.
• Facilitates and coordinates behavioral health resources as individual member needs are identified.
• Works collaboratively with the Vice President of Revenue Cycle with matters related to finance.
• May provide leadership to the Health Information Management (HIM) Team at the direction of the COO.
• Other duties as assigned

Job Qualifications

Minimum Education

• Bachelor degree in Business, Nursing or Health Care Administration for RN or Master's in Social Work for MSW
• Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license

Preferred Education

• MSN, MBA, MSW or MHA
• Accredited Case Manager (ACM)

Minimum Work Experience and Qualifications

• Ability to communicate effectively verbally and in writing.
• Must be able to work in a union environment.
• 3 years of acute hospital case management or healthcare leadership experience.
• Demonstrated organizational skills
• Excellent verbal and written communication skills
• Ability to lead and coordinate activities of a diverse group of people in a fast paced environment
• Critical thinking and problem solving skills and computer literacy

Preferred Work Experience and Qualifications

• 5 years of acute hospital case management leadership multi-site experience
• Business planning experience preferred

Required Licensure, Certification, Registration or Designation

• Los Angeles County Fire & Safety Card (required within 30 days of hire)
• Assault Response Competency (ARC) (required within 30 days of hire)

• Status: Full Time
• Shift: Exempt
• Hours: 8hrs Exempt
• Weekly/Bi-Weekly Hours: 40hrs/80hrs Exempt

FTE: 1.0