SUMMARY:The individual in this position has overall responsibility for hospital utilization management, transition management, and operational management of the Case Management Department in order to promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with all state and federal regulations related to case management services.This position integrates national standards for case management scope of services including:Utilization Management supporting medical necessity and denial prevention Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfactionCare Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care Compliance with state and federal regulatory requirements, TJC accreditation standards, and hospital policy Education provided to physicians, patients, families, and caregiverThe individual's responsibilities include the following activities: manage department operations to assure effective throughput and reimbursement for services provided, lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and hospital policy, ensure timely and effective patient transition and planning to support efficient patient throughput, implement and monitor processes to prevent payer disputes, develop and provide physician education and feedback on hospital utilization, participate in management of post-acute provider network, ensure compliance with state and federal regulations and TJC accreditation standards, other duties as assigned. QUALIFICATIONS:EducationRequired: Bachelor's degree in Business, Nursing, or Health Care Administration for RN or Master's in Social Work for MSW. Preferred: MSN, MBA, MSW, or MHA.ExperienceRequired: 3 years of acute hospital case management or healthcare leadership experience. Preferred: 5 years of acute hospital case management leadership multi-site experienceCertificationRequired: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.Preferred: Accredited Case Manager (ACM)Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy. Business planning experience preferred.PHYSICAL DEMANDS:Lift/position up to 25 lbs. Push/pull up to 25 lbs. of force.Frequent sitting. Moderate standing, walking, reaching, stooping, and bendingManual dexterity, mobility, touch, auditory to perform all the related duties of the positionIndividual wages are determined based upon a number of factors including, but not limited to, an individual's qualifications and experience The hospital complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law. ResponsibilitiesThe individual's responsibilities include the following activities:a) manage department operations to assure effective throughput and reimbursement for services provided,b) lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement,c) ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and hospital policy,d) ensure timely and effective patient transition and planning to support efficient patient throughput,e) implement and monitor processes to prevent payer disputes,f) develop and provide physician education and feedback on hospital utilization,g) participate in management of post-acute provider network,h) ensure compliance with state and federal regulations and TJC accreditation standards andi) other duties as assigned.QualificationsEducation:Required: Bachelor's degree in Business, Nursing or Health Care Administration for RN or Master's in Social Work for MSWPreferred: MSN, MBA, MSW, or MHAExperience:Required: 3 years of acute hospital case management or healthcare leadership experiencePreferred: 5 years of acute hospital case management leadership multi-site experienceCertifications:Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.Preferred: Accredited Case Manager (ACM)Physical Demands:Lift/position up to 25 lbs. Push/pull up to 25 lbs. of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position.
