Director of Care Coordination

Navajo Preference Employment Act


In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.
Overview

POSITION SUMMARY

The Director of Care Coordination is responsible for leading, supervising, managing, and coordinating multiple care coordination/social services departments to include Case Management, Utilization Review, Durable Medical Equipment/Transportation, and Purchased Referred Care. The position directs the departments and is fully accountable for monitoring program activities, including compliance, planning, implementing, and evaluating program development to ensure clinical and financial activities promote the continuum of care and appropriate use of clinical and financial resources. The position is comprised of complex managerial, clinical care coordination and administrative components, associated with critical issues affecting patient care and overall standards of patient care coordination that influence the organizational mission, health care and policy.

The Director of Care Coordination is the clinical and administrative coordinator for all aspects of care coordination including policies and practice, budgetary and administrative oversight of compliance with TCRHCC directives. This position provides oversight for the local Care Coordination department to include: administrative staff for review of eligibility, authorizations and scheduling etc., Social Workers for discharge planning and case management, Registered Nurses (RN's) for case management, utilization review, discharge planning, and processes related to review and approval of Purchased Referred Care referral requests (for justification and medical necessity), and/or denial of Purchased Referred Care referrals and/or cases, and denied/appealed care claims based on eligibility criteria.

The goals are to center services around the patient, to foster patient self-managed care, and maximize efficient and cost-effective use of health care resources. The Director of Care Coordination utilizes all avenues of resources available to ensure staff provide safe and efficient timely coordination of quality health care and services. The role of the Director of Care Coordination is to establish, promote and monitor seamless care for TCRHCC patients.


Qualifications

Education:

Bachelor's degree in nursing and Master's Degree in Business Administration or other healthcare related degree.


License:

A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States

Experience:

Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Accessing community resources for patient referrals
• Knowledge of diagnosis related groups (DRG) and documentation requirements
• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Ability to sense varying skill levels and direct instruction accordingly
• Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
• Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
• Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be provided to enable individuals with disabilities to perform essential functions.

Physical:

The work involves prolonged periods of sitting in an office setting operating a personal computer, walking throughout the hospital to obtain and review medical records, and standing while inquiring with providers and clinical staff. The Incumbent may occasionally need to drive, bend, climb, kneel, crouch, twist, maintain balance, and reach. There may be times of distant travel for ongoing and advanced training. Occasional travel to satellite health centers for on-site reviews. The Incumbent will frequently need to be able to lift, pull, and push up to 10 pounds. This position requires sensory ability for frequent use of far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and hearing overhead pages over a loudspeaker. The incumbent must be able to utilize hand manipulation to do simple grasping and use of keyboard for prolonged time during workday. The position requires frequent firm grasping and fine manipulation.


Mental:

The work requires the ability to deal relatively independently with the interrelated elements that affect data analysis and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work.


Environmental:

The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.


Responsibilities

ESSENTIAL FUNCTIONS:

1. Supervises Case Management, Durable Medical Equipment/Transportation, Patient Referred Care (PRC), Pre-Authorization, Recovery Audit (RAC) and Utilization Review staff, including hiring, training, assigning work, counseling, performance evaluation and other personnel/disciplinary actions. Develop and manage the operating and capital budget for the department. Monitors time and attendance for staff; approves leave and overtime hours. Monitors productivity and quality of work performed by all staff. Identifies and implements staffing changes which will measurably increase productivity of department operations.
2. Manages the case management and utilization review model to ensure patient care delivery is performed in collaboration and coordination with the organization's resources and multidisciplinary health care team(s) (i.e. Nurses, Physicians, Clinical Case Management, Patient Benefit Coordinators, Patient Registrars, Purchased and Referred Care).
3. Administers case management and utilization review programs and service in accordance with Federal laws, regulations, accreditation requirements, policies, procedures, and guidelines; and bases recommends to managers and professional health care providers on costs and benefits of proposed case management actions.
4. Ensure Case Management staff, develop a care delivery system/service plan based upon the patient's identified needs, available providers, financial resources, family, caretaker(s), and multidisciplinary health care team, which may include other Navajo Area Service areas and/ or other non TCRHCC providers as appropriate.
5. Works as a liaison to promote the healthcare of patients and improving care coordination between Case Management, inter-departmental staff, and outside providers. Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division.
6. Responsible for initiation, preparation, and oversight of all contracted services for the case management program and represents TCRHCC at inter-agency meetings that may impact case management policy or result in agreement to support program initiatives.
7. Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
8. Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevents over or under utilization of resources, maximizes the use of alternate resources, and supports continuity of care.
9. Assists with review, research, and decision of first level appeal process with Purchase Referred Care
10. Leads education activities to enhance the quality and completeness of clinical documentation, and patient care coordination. Makes certain training/continuing education is available for staff as appropriate either on-site or external training to improve skills in data entry of all Case Management Services referrals.
11. Ensures Utilization Review staff, conduct timely follow-up reviews of clinical documentation from pre-admission to post-discharge, continued stay, cost containment and discharge planning, and issues are discussed and clarified with the physician, and recorded in the patient's chart.
12. Ensures Utilization Review staff, collaborate with the House Supervisor and the accepting physician regarding the appropriateness of the transfer of patients from discharging outside facilities to TCRHCC or return to TCRHCC.
13. Educates and oversees the Utilization Review nurses in modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of services rendered and ensures timely submission of inpatients admissions and prior authorization for Third Party Payors (TPA).
14. Identifies utilization trends such as avoidable days, hospital acquired conditions, and denials of authorization and report these trends to appropriate Senior Leaders, committees, and staff to promote education and change within the facility.
15. Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
16. Collaborates with the Physician Advisor in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.
17. Responsible for Durable Medical Equipment (DME) and Patient Transportation programs; works with DME and Transportation staff to ensure regulatory compliances are met, including inventory management, staffing, billing requirements and patient needs are provided within the regulatory requirements and the capabilities of TCRHCC.
18. Responsible for Patient Referred Care (PRC) programs; works with PRC staff to ensure timely and efficient processing of PRC referrals as provided within the regulatory requirements and the capabilities of TCRHCC. Ensures documentation is appropriate and complete for Catastrophic Health Emergency Fund (CHEF) cases and ensures the CHEF applications are uploaded in the Indian Health Service's electronic CHEF application tool.
19. Ensure proper PPE is work at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher (if available), and eye or face
20. Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE (see CDC website for most current updates)
21. Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer
22. Performs other assigned duties as needed.