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Nurse Mgr Case Mgmt & Util Rev

Job ID 149263 Date posted 07/19/2018

Under the general direction of the Chief Nursing Officer/Associate Chief of Nursing the Nurse Manager practices within the Lahey Clinic Professional Practice Model, MA Nurse Practice Act and ANA Standards of Practice and Code of Ethics. The Nurse Manager manages and supervises all nursing staff in assigned clinical patient care units to provide quality patient care. Areas of responsibility include:
• Clinical practice
• System coordination
• Quality improvement
• Human resource management
• Unit budget
• Professional growth
• Self-improvement
The Nurse manager of Case management and Utilization review specifically oversees all aspects of Hospital Based Case Management, and Utilization Review in collaboration with the medical director Develops implements and evaluates the strategic plan for the Hospital Based Case Management process to coordinate within a system wide Care Management process. Provides operational supervision of the Case Managers Coordinates and supports ongoing problem solving. Establishes tools, processes, and systems to support the Case Management process and optimize outcomes.
The Nurse Manager maintains a current level of knowledge with management leadership skills as defined by nursing specialty organizations, complies with all regulations and standards of regulatory and accrediting bodies, and is currently licensed in the state of Massachusetts as a registered nurse.


1. Creates data priorities and report formats that display critical outcome factors, inclusive of LOS, payer data , referral patterns
2. Provides feedback to the department staff regarding Case Management sensitive data findings.
3. Identifies appropriate staffing levels, assignments, and deployment for the department.
4. Establishes role descriptions and performance criteria for staff members.
5. Identifies organizational needs and concerns in payer-provider contracts and contributes to related negotiations.
6. Establishes effective relationships with individual physicians, physician groups, and physician organizational structures.
7. Establishes processes and policies that adhere to Joint Commission standards as well as CMS Conditions of Participation and other regulations.
8. Collaborates with Compliance to ensure developed processes and policies meet compliance standards.
9. Establishes a Utilization Management Committee, participates in the selection of standing agenda items, and provides reports and data to be reviewed.
10. Develops structures and processes to facilitate participation by physicians, pharmacists, nurses, Social Workers and other health professionals in multidisciplinary care planning, care delivery, and discharge planning.
11. Establishes effective communication systems and forums with third party payers and the local QIO/PRO.
12. Develops and maintains effective relationships with hospital department heads, nursing managers and administrators, and the administrative staff.
14. Develops relationships with LHS accountable care organization as well as with outside preferred providers SNFS and Home Health Agencies etc.
15. Evaluates and optimizes patient satisfaction with discharge planning functions.
16. Directs utilization review activities for the hospital, interfacing with external payers and review companies to determine appropriate medical necessity of admissions and continued hospitalization.
17. Resolves conflicts related to discharge planning with patients/families, external agencies and payers.
18. Facilitates transition of patients/families across the continuum by establishing relationships with appropriate providers and community services.
19. Establishes policies, procedures and protocols for departmental functions.
20. Establishes a structure and process to address the CMS RAC initiative related issues within the organization that is aligned with other departments such as Finance and Compliance.
21. Responsible for implementation of policies and procedures related to hospital based case management, utilization review,

A. Develops implements and assures compliance with Nursing Practice Guidelines.
B. Encourages staff participation on Shared Governance Councils, nursing committees, and organization committees.
C. Maintains and displays knowledge of current professional/clinical issues and uses evidence based resources to implement necessary changes in the delivery of nursing care.
D. Collaborates with leadership team to provide opportunities for staff development. i.e.:
• Participation in nursing research.
• Certification in nursing field
• Participation in professional organizations.

A. Links departmental goals to organizations mission and goals.
B. Works collaboratively to solve problems, improve processes and integrate services within the department and with other departments.
C. Supports new ideas and changes within the department by actively participating and contributing.
D. Demonstrates flexibility in meeting demands of the department.
E. Organizes and prioritizes work to meet deadlines.
F. Develops effective communication methods to keep staff and others informed about activities of the organization and department.

A. Proactively develops plans to meet future departmental/organizational needs.
B. Reviews outcome measures and works collaboratively with staff and leadership team to improve patient outcomes. Ie: National Database of Nursing Quality Indicators (NDNQI) and Core Measures
C. Collaborates with multi-disciplinary teams to:
• Comply with regulatory standards
• Improve patient satisfaction
• Improve patient outcomes
• Identify, assess, measure and systematically improve important processes and activities.
A. Works collaboratively with the Human Resources Department and Senior Leadership to recruit, hire and retain qualified personnel.
B. Oversees and conducts performance appraisals. Collaborates with Senior Leadership and Human Resources to recommend compensation adjustments.
C. Assures appropriate orientation, competence assessment, in-service training and continuing education for all staff.
D. Fosters staff development by assisting them to identify goals and appropriate opportunities for learning.
E. Encourages creativity and celebrates staff accomplishments.
F. Promotes an environment that is sensitive to the diverse needs of the patients and employees.
G. Coaches and supports staff by removing barriers and addressing issues.
H. Assures licensing certification for all staff is current.
I. Conducts regular staff meetings.
J. Communicates staffing concerns to Associate Chief.
K. Delegates work appropriately and provide direction and guidance to nursing and support staff.

A. Participates in development of annual departmental budgets.
B. Develops and implements cost effective staffing patterns.
C. Uses resources effectively to provide high quality cost effective services.
D. Monitors budget and prepares variance reports.
E. Maintains ANSOS and assures vacancy rate/position control is current.
F. Manages expenses on an on-going basis and identifies areas of potential cost savings.

A. Pursues self-awareness, actively seeks feedback, accepts constructive criticism, and modifies behavior accordingly.
B. Engages in professional development activities such as education, participating in professional associations, or other appropriate activities.
C. Maintains necessary continuing education requirements for license, certifications and enhancements.
D. Maintains own educational record.
E. Supports Lahey Clinics commitment to community based activities both within the Lahey community and beyond.

A. Incorporates Lahey Clinic Guiding Principles, Mission Statement and Goals into daily activities.
B. Complies with all Lahey Clinic Policies.
C. Complies with behavioral expectations of the department and Lahey Clinic.
D. Maintains courteous and effective interactions with colleagues and patients.
E. Demonstrates an understanding of the job description, performance expectations, and competency assessment.
F. Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
G. Participates in departmental and/or interdepartmental quality improvement activities.
H. Participates in and successfully completes Mandatory Education.
I. Performs all other duties as needed or directed to meet the needs of the department.


Minimum Qualifications:
Education: Graduate of Approved/accredited School of nursing.

Licensure, Certification, Registration: Current licensure to practice professional nursing in the Commonwealth of Massachusetts.
Life Support Certification:
Special skills and knowledge required:
1. Knowledge of payer requirements and discharge planning regulations that support the effect development of departmental policies, procedures and standards.
2. Demonstrated ability to: Establish the goals, vision, and overall direction of a department; create and implement departmental standards, systems, staffing plan and processes; analyze issues and create and effective plan to address them; critically and comprehensively evaluate the department?s outcomes; identify, collect and analyze data related to the internal and external environment as well as departmental functioning; and, develop and educate staff.
3. Demonstrated ability to communicate verbally and in writing to internal and external constituencies.
4. Ability to establish priorities, meets deadlines, and develops and manages the department?s productivity standard in the management of work assignments.
5. Ability to form positive, collaborative relationships with members of the executive team, hospital staff, post-acute providers and p

Skills, Knowledge & Abilities:
Clinical Skills/Technical Knowledge
a. Demonstrates the necessary clinical competence in area of nursing practice.
b. Excellent interpersonal and organizational skills.
c. Basic computer skills.

Experience: A minimum of five years of accumulated in-patient nursing experience and two years leadership experience.


DAYS. 8 hour shifts Monday-Friday

About Lahey Health

At Lahey Hospital & Medical Center, as one of the world's premier health care organizations, we provide superior health care leading to the best possible outcome for every patient. We exceed our patients' high expectations for service each day. We also help advance medicine through research and the education of tomorrow's health care leaders

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