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Utilization Review Associate Director RN, Case Management, Full Time, Days

3 months ago

Miami, United States Jackson Health Full time

Department: Jackson Memorial Hospital - Utilization Review Case Management Leadership

Address: 1611 NW 12 Ave., Miami, FL 33136

Shift details: 8:00 - 4:30 PM, Monday - Friday (remote position, must live within one hour from facility)

 

Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century. Throughout its rich and storied history, Jackson Memorial - located in the heart of the City of Miami - has been ground zero for some of the world's greatest medical breakthroughs and important moments in South Florida. We've grown into one of the nation's largest public hospitals, and one of the few that is also a world-class academic medical center with a proud mission and proven success. Jackson Memorial is an accredited, tertiary teaching hospital with 1,500 licensed beds, where nearly every medical specialty is provided by some of the world's most skilled and highly regarded multidisciplinary team of healthcare professionals.

Summary

Associate Director of Case Management is a leadership member of the health care team who has 24/7 day accountability for the coordination, monitoring, and management of patient care resources to promote the most efficient delivery of patient care services at the appropriate level while maintaining a single high standard of care delivery to all patient populations. The Associate Director of Case Management acts as a resource to all levels of staff and management in defining/implementing and evaluating patient care and nursing practice standards utilizing clinical expertise, the nursing process, current concepts/principles of case management/utilization management/disease management, quality improvement, clinical practice and health care trends.

Responsibilities

  • Identifies practice issues, system issues and trends utilizing medical criteria, clinical data systems and protocols. 
  • Performs problem resolution activities to maintain quality patient care. 
  • Develop material and present at administrative meetings; Case Management metrics and productivity to include but not limited to: utilization management, denials, length of stay (LOS) and discharge planning. 
  • Management oversight of patient throughput: assessment and evaluation to determine appropriate level of care and appropriate hospitalization status (inpatient, observation, or outpatient procedure) beginning with point of entry continuing through discharge. 
  • Management oversight of the Clinical Resource Coordinator's (CRC) performance: utilization management, denials, LOS, discharge planning, and staff management. 
  • Collaborates with other disciplines regarding scope of work, including but not limited to Chief Medical Officer (CMO), Physician Advisor (PA), Nursing and Revenue Cycle. Patient Care Rounds: provides leadership and oversight for effective communication of pertinent clinical status, appropriate level of care, discharge delays, discharge planning and LOS. 
  • Maintain leadership visibility, supporting service excellence initiatives, and focusing on improved employee and patient satisfaction. 
  • Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). 
  • The leader understands and adheres to JHS compliance standards as they appear in the Code of Conduct, Compliance Policies, and all other JHS Policies and Procedures and supports the commitment of JHS in adhering to federal, state and local laws, rules and regulations governing ethical business practices for health care providers by demonstrating knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family and organization information. 
  • The leader further understands that JHS is committed to its role in preventing health care fraud and abuse and complying with applicable state and federal laws related to health care fraud and abuse. 
  • This commitment is supported and enabled through an anonymous hotline which serves as one of several mechanisms for reporting suspected fraud, waste and/or abuse, as well as other compliance related issues.
  •  The leader to report through any of the reporting mechanisms (e.g., anonymous hotline, supervisor, Compliance Officer) any suspected health care fraud, waste and/or abuse as well as other compliance-related issues. 
  • Performs all other related job duties as assigned.

 

Experience

  • Generally requires 5 to 7 years of related experience. Leadership experience is required.

Preferred Experience

  • Strong clinical background, highly preferred.
  • At least five (5) years's experience in utilization review either in a hospital setting, or at a health plan organization, strongly preferred.
  • Denials/Appeals experience, highly preferred.
  • Strong clinical background 
  • Knowledge of CMS regulations, highly preferred.
  • Experience in managing a team, including training, mentoring, and performance evaluation.

 

Education

Bachelor's degree in related field is required

Preferred Education

Master's degree, strongly preferred

 

Credentials

Valid Florida RN license is required. Case Management certification is preferred.

 

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.