This position is responsible for the overall leadership, strategic direction and oversight of operations of Phoenix Children`s Hospital Care Coordination Departments across the enterprise, which include Inpatient Care Management, Utilization Management, and the Social Work Department, including inpatient and outpatient social workers and Licensed Clinical Therapists. This position manages existing Care Coordination vendor relationships, implements and manages a population health program with the goal of lowering the cost of healthcare and improving clinical outcomes through advocacy, partnership and innovation.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- Works in conjunction with the Medical Director, Utilization & Document Integrity and provides administrative direction and oversight of the Utilization Medical Review Committee in accordance with the requirements of the Medicare and Medicaid programs.
- Develops and establishes effective reporting and documentation systems that ensure required functions are performed; Medical Necessity reviews; including reviews of the appropriateness of admissions (observation versus inpatient admission status), lengths of stay, professional services, including drugs and biological.
- Maintains reporting systems to identify and review inpatient services determined to be outliers based on extended length of stay or that have extraordinarily high costs. This includes implementation of an escalation policy that ensures management is notified when determination is made that the patient does not meet medical necessity criteria.
- Develops and implements an integrated process for the functions of Care Coordination, Utilization Review and Discharge Planning which includes working collaboratively with other disciplines and reviews the process for continuous quality improvement.
- Directs day to day operations ensuring compliance with regulatory and legal requirements, quality standards, and which meets or exceeds community standards of care.
- Ensures that cases identified as risk management issues, peer review issues, or quality issues are reported to the appropriate personnel and documented in the appropriate clinical or administrative system.
- Assists department management in developing staff. Works collaboratively with the Medical Director, Utilization & Document Integrity in the ongoing professional development of the case management and social work teams.
- Advocates with system partners for the appropriate level of care and reimbursement available for a patients documented clinical need, and ensure that appropriate transfer arrangements are completed and in compliance with EMTALA requirements. .
- Develops and implements reporting systems to capture and review all re-admissions within 15 and 30 days from the last discharge to improve quality of care, identify opportunities to improve the discharge process and ensure compliance with regulatory and contractual requirements.
- Monitors patient and family satisfaction through system approved measures, and provides oversight in the development and monitoring of any departmental quality clinical initiatives.
- Consults with medical and hospital staff in interpreting requirements for the appropriate level of care, identifies optimal approaches to cover acute hospitalization stays. Establishes and facilitates interdisciplinary discharge rounds.
- Strategically evaluates the past, present and future objectives of the organization to align the Care Coordination Department with the overall mission and vision of Phoenix Children`s Hospital.
- Creates innovative new programs that implement cutting edge Care Coordination practices in the Pediatric Healthcare Setting.
- Develops an enterprise wide strategic workflow to transition patients both domestically and internationally.
- Ensures inter-departmental collaboration to mitigate potential revenue loss .Facilitates collaborative, team-oriented communication that improves throughput throughout the enterprise.
- Ensures that the Care Coordination leadership maintains compliance with local, state, federal regulations and laws.
- Identifies areas across the enterprise that have opportunities to capture missed revenue.
- Strategically works with internal and external vendors to enhance transitions of care and provide leadership in Pediatric Healthcare Systems in the Southwest.
- Evaluates available sources of data, both health plan specific and internal available data, to drive decisions and prioritize projects, productivity standards and patient outcome measures.
Education and collaboration with human resource department
- Participates in the selection process and makes hiring decisions with department managers. Has the authority to hire, terminate, advance, promote in coordination with department managers and Human Resources. Evaluates managerial performances and completes annual performance appraisals.
- Provides department managers the tools to determine and monitor workload productivity standards for staff.
- Provides oversight with department leadership in the development of department policies and procedures, to ensure compliance with local, state and federal regulations and laws.
- Strategically uses multiple sources of data to identify trends and potential for performance improvements. Makes recommendation to inter and intra departmental leader to provide training based on identified need.
Community provider liaison/customer service
- Serves as a Phoenix Children`s Hospital representative and resource for Community and Regional services appropriate for the continuity of care post hospitalization. This includes, but not limited to, Home Healthcare Agencies, Long term care and Rehab facilities and medical equipment companies and medical transports.
- Strategically work with internal and external vendors to enhance transitions of care and remain the leader in Pediatric Healthcare System in the Southwest.
- Mentors internal and external members of the healthcare team, to improve the overall care and transition of patients. Exhibits clear communication skills with all internal and external customers. Provides excellent service routinely in interactions with all customers. coworkers, patients, visitors, physicians, volunteers, etc.
- Provides oversight for development and continuous improvement of a collaborative, service line focused concept for care management practice, which promotes continuity of care, improved utilization of clinical and financial resources, strengthens professional relationships, and ensures appropriate patient outcomes are met in the most effective manner.
- Facilitates integration of clinical reviews to maximize efficiency with HIMS/coders in reviewing records for necessary clinical documentation and coordinates education efforts with providers to improve documentation efforts.
- Participates with key leadership in the design, implementation and monitoring of the denial management program.
- Establishes a collaborative relationship with physicians, medical directors, nurses and other unit staff, HRC/PRC management and staff and payers to better understand and convey medical practice issues to achieve improved clinical outcomes and improved revenue generation.
- Evaluates variance analysis data; clinical audits, documentation, national best practices and protocols in the care management and population health areas to integrate proven alternatives into the strategic direction of the Department, including modifying workflows and activities to achieve improves outcomes and to elevate practices.
- Develops strategic initiatives based on data to address complex business and clinical issues.
- including DRG Management, status of patients (e.g., Observation, Inpatient, Extended Stay), IT implementations and process improvement initiatives.
- Utilizes data driven information from Decision Support, payers and other CHA hospitals to develop department/enterprise priorities, including identification of strategic opportunities and improving practices. Consistently reviews PHIS data and collaborates with other CHA hospitals to develop strategies to address issues.
- Engages in business process re-engineering to redesign human resources, process and technology issues.
- Performs miscellaneous job related duties as requested.