ROLE PURPOSE

• Responsible for designing optimal care pathways, including facilitating appropriate lengths of stay and reimbursement for all hospital admissions in accordance with goals and objectives.
• Creates and embeds clinical guidelines to promote the safe care and optimal health outcome for all PLT customers

KEY ACCOUNTABILITIES

• Oversees the development and management of pathways, procedures and processes for high risk populations across the continuum focusing on high-risk, high-cost patients.
• Works to develop clinical pathways, continuum care management programs, measurement and feedback of performance indicators for cost, quality and service and patient satisfaction.
• Serves as the primary information resource for PLT staff, physicians, other healthcare team members and customers (skill areas include regulatory requirements, pathway development/implementation, ethics/healthcare law, clinical skill, etc.)
• Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; proactively monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication of other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in OnePulse screens and patient records.
• Facilitates learning experiences of healthcare team members, conducts in-services, and/or serves as a resource for pathways. Participates in training claims team and digital product team.
• Initiates and leads the development, implementation, evaluation and revision of clinical pathways and other Case management tools.
• Assists in compilation of physician profile data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction and quality indicators (e.g., readmission rates, unplanned return to OR, etc.)
• Escalates and investigates cases where incorrect treatment plan is being applied.
• Develops Utilization Management and Quality Screening for PLT inpatient customers
• Proactively works with Provider Management team to ensure LOS and treatment costs are reviewed and challenged (where appropriate) by ensuring timely data is being provided to the Provider Management team and to the network partners.
• Leads and supports claims team to ensure clinical guidelines are embedded to day to day claims operations.

KEY ATTRIBUTES

• Minimum five (5) years’ experience in utilization management, case management, discharge planning or other cost/quality management program
• Three (3) years of experience in hospital-based nursing or clinical role required
• Excellent interpersonal communication and negotiation skills
• Demonstrated leadership skills
• Strong analytical, data management and PC skills
• Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement
• Understanding of pre-acute and post-acute venues of care and post-acute community resources
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Ability to work independently and exercise sound judgment in interactions with physicians, partners, and patients and their families
• Effective oral and written communication skills