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 satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at the appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards, and hospital policy
- Education provided to physicians, patients, families, and caregivers
The 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
Education
Required: Bachelor degree in Business, Nursing or Health Care Administration for RN or Master's in Social Work for MSW.
Preferred: MSN, MBA, MSW or MHA.
Experience
Required: 3 years of acute hospital case management or healthcare leadership experience.
Preferred: 5 years of acute hospital case management leadership multi-site experience.
Certification
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).
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.
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