Under the leadership of the Vice President/COO, the Director, Case Management is an active member of the department that collects and analyzes data. The Director, Case Management is responsible for the management of the Utilization/Case Management Department and the collection, aggregation, analysis, and reporting of complex clinical data. The Director conducts and oversees ongoing reviews of medical cases to support the efficient utilization of clinical resources and clinical improvement activities. The Director works with the staff to prepare case reviews that ensure appropriate reimbursement for medical services, satisfies requirements of accrediting organizations, and supports clinical improvement activities.
Requires a Bachelor's degree in Nursing from an accredited school of Nursing. A Master's degree in Nursing is preferred.
Requires five to seven years of work-related experience or an equivalent combination of education, training and experience.
- Licensure, Registrations & Certifications:
Requires a current state license as a Registered Nurse and is listed in good standing with the state's Department of Professional Credentialing. A Certified Case Manager certification is preferred.
Requires a current certification in BLS. (If BLS verification is not current upon hire, it must be obtained within three (3) months of hire.)
Essential Job Responsibilities:
- Leads and manages the Utilization/Case Management Department and staff.
- Converts CRHS's vision and goals into actionable plans and directions related to the operation of the Utilization/Case Management Department.
- Establishes both short and long-term goals for the Utilization/Case Management Department and prepares corresponding strategic and annual financial plans, ensuring budget variances are within acceptable limits.
- Provides overall leadership, management, development and evaluations for the Utilization/Case Management Department's staff.
- Represents Utilization Management at various committees, professional organizations, and physician groups.
- Prepares and updates policies and procedures for the Utilization/Case Management Department, incorporating input from the department's staff, and ensures their compliance with all federal and state laws and regulations.
- Guides the Utilization/Case Management Department in an interactive role of teaching physicians and departments of regulations affecting utilization management. Develops and facilitates educational programs within the Utilization/Case Management Department.
- Manages the review of medical records to determine the appropriateness of admissions, procedures, and the necessity of continued hospital stay, based on Centers for Medicare and Medicaid Services (CMS) guidelines.
- Performs continuing review of the medical record, identifying the need for ongoing hospitalization through the evaluation of clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes. Identifies and certifies for billing and hospital utilization/case management purposes, the acute hospital length of stay authorized for each case.
- Performs medical record reviews interpreting, abstracting, aggregating, analyzing and reporting complex clinical data obtained from medical records.
- Maintains a reporting and recording system and has the knowledge of clinical practice guidelines, appropriateness of clinical interventions and treatment modalities, medical terminology, and appropriate levels of healthcare.
- Complies with third party payer requirements, identifies those patients requiring pre-admission, pre- procedure, and continued stay authorizations, and obtains those authorizations necessary for reimbursement.
- Provides consultation regarding the level of nursing care required when nursing home placement is planned and works collaboratively with other departments in the development and evaluation of projects affecting discharge planning.
- Manages monthly operating financials for the Utilization/Case Management Department and works with the CFO or other members of Administration to develop proactive remedial actions when necessary.
- Works to continually improve the quality and timeliness of the Utilization/Case Management Department services.
- Maintains and updates the department's safety plan and ensures the plan complies with JCAHO requirements.
- Serves on CRHS and Nursing committees and task forces concerning patient care, safety, security, quality, performance improvement and staff-related issues.
- Works closely with the Vice President/COO and the Administrative Team to recommend and maintain an organizational structure and staffing levels to accomplish operational goals and objectives.
- Provides staff the opportunities to participate in staff development and regularly schedules in-service programs. Provides new employees with an orientation specific to the department, explaining the department's mission and goals.
- Prepares and conducts probationary and annual employee evaluations that accurately reflect the employee's performance during the evaluation period. Provides the employees with a summary of their strengths, areas for improvement and developmental plan for the future.
- Utilizes technology to analyze and develop statistical measures of the Utilization/Case Management Department's performance metrics, reports and programs.
- Ensures the continuous survey readiness of any and all regulatory agencies including Joint Commission, EEOC and other governmental agencies.
- Performs other duties as assigned.
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