Emeryville, CA, 94662, USA
21 days ago
Senior Director, Care Mgmt
We are so glad you are interested in joining Sutter Health! **Organization:** SHSO-Sutter Health System Office-Valley **Position Overview:** Play a critical role in Sutter Health's pursuit to transform healthcare by achieving the highest levels of quality, access, and affordability. Partner with leadership to achieve strategic initiatives such as Total Care Accountability, developing new product offerings and building partnerships related to healthcare reform opportunities. Oversee the planning and execution of care management activities to improve the coordination and transition of care. Develop systems and day-to-day operations to manage care across Sutter Health's continuum of healthcare services—acute, ambulatory, and palliative. Collaborate with to explore optimization opportunities, to identify business efficiencies and linkages, and to encourage cross-organization communication that enhances our competitive advantage and fosters a "One Sutter" face to our patients and their families. Lead and promote system-wide and OU-based best practices related to care management resources, continuity of care, disease management, and clinical outcomes of all case management and social services in both inpatient and outpatient settings. Deliver measurable results that reveal a higher level of quality care through expanded services and performance efficiencies while offering a cost-effective and value-add healthcare environment to our patients, caregivers and customers. Where this job exists at a large affiliate, as defined as: Bay Foundation, Valley Foundation and Operating Unit (OU) roles, and reports to an Executive-Path leader, the title will be Executive. **Job Description** : _These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development)._ **JOB ACCOUNTABILITIES:** Develop and implement a comprehensive care management program that is consistent with Sutter Health's strategic initiatives while addressing current and future care continuum elements for acute, ambulatory and palliative settings. • Participate in developing, maintaining, updating and achieving approved short and long range care management plans for the operation unit • Solicit, evaluate and incorporate input from top leadership, patient feedback, targeted audience populations, key learnings, and regulatory changes to formulate a foundation for an effective care coordination strategy. • Ensure adherence to system-level practices, policies and procedures in the development of comprehensive and cost-effective care management solutions that are consistent with Sutter Health’s strategic objectives and that deliver a high level of quality care with exceptional service. • Evaluate disease management programs and offer recommendations to leadership regarding internal program development or purchase (in coordination with system-wide operations). Achieve operating unit care management objectives through effective operations administration. • Deliver smooth functioning, efficient operations through timely and effective problem resolution; promptly addressing potential issues, determining root cause and offering effective solutions that can be replicated across the enterprise. • Establish and monitor appropriate financial management control mechanisms for all assigned hospital and non-hospital based operations; meeting or exceeding budgetary goals with regard to revenue and expenses. • Identify, develop and modify methods and techniques to leverage technology improvements that afford economies of scale while increasing effectiveness and efficiency. • Develop, implement and revise techniques and practices to deliver the highest quality of care while working in a patient-focused manner. • Monitor quality and scope of medical and nursing care for effectiveness, evaluate deviations and pursue necessary improvements including notifying appropriate leadership. • Ensure the proper and timely reimbursement from government and third party payers to the. appropriate care management entity. Plan, design, monitor and analyze the case management program for entities within the operating unit. • Implement case management programs that crosses the operating unit continuum of care and aligns with corporate guidelines and policies • Ensure case management operations (where applicable) comply with National Committee for Quality Assurance (NCQA) utilization management standards • Establish preemptive and proactive model to prepare an entities for successful recovery audit contractor (RAC) responses, including unscheduled audit drills to identify potential problems and integrating technology to manage the RAC process. • Provide leadership and direction in planning relevant care/case management committees. Lead efforts to develop metrics and key performance indicators for the operating unit, starting with each hospital. • Deliver periodic updates on the progress and timelines of long range care management objectives, initiatives, and strategies to leadership, operating unit staff, and physicians • Aligns case management programs and best practices across the operating unit and enterprise to achieve regional and corporate integration and consistency. Promote and encourage the vision of “One Sutter” by developing and implementing effective mechanisms for standardization and collaboration among the various entities within the operating unit and across the Sutter Health care continuum. • Oversee the implementation and monitoring of the necessary care management principles, policies and procedures to ensure the operating unit meets and/or exceeds regulatory, industry and clinical standards • Comply with all applicable legal requirements, standards, policies and procedures including, but not limited to Health Insurance Portability and Accountability Act (HIPPA) and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. • Foster an environment for proactively sharing best practices, sponsoring guest speakers, developing tool box approach to issues such as observation and transportation compliance • Champion continuous improvement and advise diverse audiences (staff, management and medical leadership) on quality improvement activities, long range strategies, annual objectives and goals and organizational policies and procedures. • Incorporate review feedback and recommendations from inspecting agencies (voluntary and governmental) to modify operations accordingly • Develop and implement effective mechanisms for collaboration across the operating unit to identify and optimize OU resources and services that result in cost-effective healthcare solutions. Build effective working relationships with all levels of internal and external constituencies, including executives, physicians and community boards to deliver cost-effective healthcare management solutions for priority populations. • Pursue local, regional and national linkages to identify opportunities to strengthen and grow Sutter Health’s care management services • Foster strategic partnerships with staff, leadership, physicians, community members, and vendors to identify and deliver effective care management strategies that meet the needs of targeted populations within the operating unit. • Cultivate and maintain an expertise in local and national trends in healthcare delivery, changes in legislation and accreditation standards, as well as developments in case management as they apply to care coordination, payment methodologies, discharge planning, social services and contracting. **EDUCATION:** Graduate of an accredited school of nursing **CERTIFICATION & LICENSURE:** RN-Registered Nurse of California **TYPICAL EXPERIENCE:** 15 years of recent relevant experience. **SKILLS AND KNOWLEDGE:** Expert level clinical knowledge in the area of care management principles as they relate to population health as typically acquired during 5-7 years of experience in senior level clinical management Comprehensive knowledge of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation related to utilization review and discharge, including other federal and state regulations related to case management, social work, etc., across the care continuum General knowledge of the health benefits business, clinical issues, market trends, medical management, medical care delivery systems, utilization management, quality management, contracting, benefits interpretation, provider relations and government rules and regulations impacting potential health care reimbursement Working knowledge of state and federal regulations governing immunity for peer review confidentiality Thorough knowledge of capitation and all of its implications to care delivery operations and management, including demonstrated success at improving the efficiency and effectiveness of large groups of physicians in significant capitated markets In-depth knowledge of: utilization review, case management, managed care, clinical effectiveness, clinical pathways, disease management, recovery audit contractor (RAC) responses and quality improvement (QI) initiatives Working understanding of business planning including analysis, statistics, budgeting, feasibility studies and implementation Understanding of and experience with Lean or other process improvement philosophies and methodologies desired Established ability to define and implement an area-wide care management philosophy, goals and objectives, standards, and policies and procedures to achieve stated objectives while aligning with corporate strategies and goals Proven skills in leadership, facilitation, organization, prioritization, time management, team building, project management, negotiation and conflict identification and resolution Demonstrated ability to work within and across all levels of a large health care organization, creating value and buy-in as a key driver of functional and cost-effective continuum of quality care Written and verbal communication skills, including the ability to translate complex medical and business concepts into lay terms for diverse audiences including ceo's, medical group foundations, independent physician associations (ipas) and hospitals Superior analytical and problem solving skills, including the proven ability to deliver effective solutions and build consensus, while fostering collaborative working relationships with internal and external constituencies Exceptional attention to detail, with the proven ability for critical thinking in investigating and assessing complex issues, organizing and analyzing data, interpreting healthcare laws and regulations, andformulating constructive solutions Advanced level of computer competency in Microsoft Office Suite, as well as other relevant software for research and analysis **Job Shift:** Days **Schedule:** Full Time **Days of the Week:** Monday - Friday **Weekend Requirements:** Occasionally **Benefits:** Yes **Unions:** No **Position Status:** Exempt **Weekly Hours:** 40 **Employee Status:** Regular Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans. Pay Range is $91.30 to $146.08 / hour _The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package._ _​_
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