Position Overview: The individual in this role holds overall responsibility for hospital utilization management, transition management, and operational management of the Case Management Department. This is aimed at promoting effective use 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.

Key Responsibilities:

Utilization Management:

Support medical necessity and denial prevention.

Transition Management:

Promote appropriate length of stay, readmission prevention, and patient satisfaction.

Care Coordination:

Ensure throughput efficiency while assuring care is provided in the correct sequence and at the appropriate level.

Compliance:

Adhere to state and federal regulatory requirements, TJC accreditation standards, and hospital policies.

Education:

Provide education to physicians, patients, families, and caregivers.

Operational Responsibilities:

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 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 the management of the post-acute provider network.

Ensure compliance with state and federal regulations and TJC accreditation standards.

Perform other duties as assigned.

Qualifications:

Education:

Required: 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.

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.

Certifications:

Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified, or registered to practice the profession as required by law or regulation in the state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.

Preferred: Accredited Case Manager (ACM).

Skills:

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.

Computer literacy.

Business planning experience preferred.