Work Shift: DAY
Work Week: M - F
Under direction is responsible for functional and operational aspects of the Case Management / Social Work Department, an integrated, multi-disciplinary department which supports caregivers to provide the highest quality, most clinically appropriate care to patients and while promoting the most cost-effective utilization of the hospital¿s resources. Provides leadership, guidance and direction to staff. Maintains accountability for level of unit performance and results. Responsible for quality, functional excellence and contribution to accomplishment of strategic and operational objectives. Accountable for the design, implementation, training, and resources for the Care Management system for the organization. Possesses the ability to interact with corporate and hospital administrators, medical staff, and defined customers related to the Care Management system. Responsible for the Care Management reporting system to ensure organization priorities are appropriately addressed in all facilities.
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 20 %
1. Provides the leadership to have a competent and satisfied employee group by doing timely performance appraisals, providing development and mentoring of subordinates and staff. Hires, coaches, trains, disciplines and terminates staff as necessary. (EF)
SERVICE - 20 %
1. Plans and organizes day-to-day operations, schedule and activities of the work group. Sets priorities and functional standards; gives direction to staff as necessary. (EF)
2. Makes and executes decisions within delegated authority. Surfaces issues to management for resolution as appropriate. Participates in resolving issues outside delegated scope of authority. (EF)
QUALITY/SAFETY - 30 %
1. Supports maximization of Care Management system utilization. Recommends appropriate uses for the Care Management system. Collaborates with departmental management and/or staff, Information Technology (IT) personnel, other functional areas, and software vendors as appropriate to determine information needs and ensure timely information updates. (EF)
2. Conducts special studies, performs informational analysis, and develops special reports as requested through system tools and resources. Generates reports to identify trends and opportunities for process improvement. Prepared data for presentation.
Develops audit reports to identify quality issues and to identify areas for enhanced staff training. (EF)
3. Manages Utilization Management (UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals. Collaborates with the Director of Case Management/Social Work on Criteria and Policy Key Development, and the Prior Authorization List. Collaborates with Physician and Nursing leaders and external entities to develop, implement and evaluate UM program policies as directed and ensures UM programs are consistent with national accreditation guidelines.
4. Provides leadership to ensure operational effectiveness and efficiency of retrospective UM and medical claims functions to meet and exceed service-level goals and contract requirements. Oversees the quality assurance and quality improvement processes related to retrospective UM and medical claims programs. Collaborates with medical and clinical leadership to implement new processes for enhancing service levels. (EF)
FINANCE - 20 %
1. Participates in planning, budgeting and general management efforts for the department of which the unit is a part and stays within budget. (EF)
GROWTH/INNOVATION - 10 %
1. Evaluates departmental procedures and operations as they relate to information technology and recommends changes to improve efficiency and effectiveness as appropriate. Ensures the effective use of departmental information system by coordinating initial training for new users and ongoing training departmental staff of system upgrades, changes, and new functions as necessary. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
o For RNs
Bachelor¿s of Science in Nursing (BSN) degree required for RN applicants; Masters preferred
o For Social Workers
Bachelor¿s degree and Masters degree in Social Work (MSW) required for Social Work applicants.
o Five years experience in inpatient case management, social work or utilization management department or in the managed care/payer environment.
o Management Experience preferred.
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
o For RNs
Must have valid Texas RN licensure.
o For Social Workers
Licensed Masters Social Work (LMSW) required
Licensed Clinical Social Work (LCSW) preferred
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
o Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations.
o Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
o Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.
o Leadership skills
o Computer literacy
o Advanced written and oral communication skills
o Excellent analytical skills
o Advanced negotiation and mediation skills
o Advanced time management and prioritization skills
o Expert collaboration skills
Work Attire Yes/No
Business professional Yes
Other (dept approved) Yes
On-Call* No (for Non-Exempt or Exempt jobs)
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.
May require travel within Yes
Houston Metropolitan area
May require travel outside No
of Houston Metropolitan area
**Travel specifications may vary by department.
Houston Methodist is an Equal Opportunity Employer.
Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.
VEVRAA Federal Contractor – priority referral Protected Veterans requested.
Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers nearly 200 beds, 16 operating rooms and over 1300 employees, with access to the most innovative medical and surgical care available, including robotic and minimally invasive surgery, full-spectrum heart care, state-of-the-art imaging, cancer care, labor and delivery with a level II neonatal ICU, neurology and neurosurgery, orthopedics and sports medicine, outpatient rehabilitation and 24/7 emergency services.
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