Director of Case Management

Provides administrative leadership to the Department of Case Management with responsibility for Utilization Review, Integrated Clinical Service, Discharge Planning and Care Transitions in accordance with Federal/State legal and regulatory requirements, as well as private payer guidelines. The Director is responsible for maximizing access to and efficient utilization of resources in an integrated multidisciplinary patient care management program, with focus on correct patient placement status, patient throughput, length of stay, and safe, timely transitions of care. Chairs the quarterly Utilization Review Committee, collecting, analyzing and reporting data on key metrics; responsible for preparation of agenda, minutes and dissemination of reports. The Director must ensure effective, timely communication with key stakeholders across the care continuum including patients, families, physicians, payers, and representatives of other healthcare entities. Must effectively utilize established medical necessity criteria for inpatient admissions and observation placement, as well as transitions of care impacting length of stay and readmissions, with specific focus on high risk populations. The Director must take an active leadership role in daily interdisciplinary patient rounds and LOS meetings to facilitate timely, appropriate, cost effective patient transitions. The Director must possess in-depth knowledge of Medicare (RAC), Medicaid and commercial claims review and denial processes, with administrative accountability for appeals preparation and submission. Must have strong leadership and communication skills to direct and mentor the case management team, while fostering a culture of ownership and accountability.

Education/Training:

• BSN Required, Master’s Degree Preferred

Licenses/Certification:

• Current MA licensure

Required Qualifications and Skills:

• Minimum of 3-5 years of progressively responsible experience in a Case Management leadership role including but not limited to: Utilization Review/Denials Management, Discharge Planning, Integrated Clinical Service/Care Coordination, Patient Throughput/LOS Management with solid track record of collaborative relationships with physicians, colleagues, and key stakeholders.
• In depth knowledge of acute care Case Management to include medical necessity, utilization review, LOS management, readmission reduction, denials management and effective transitions of care impacting revenue cycle
• Expert computer knowledge for quality, data management and analysis, documentation and reporting
• Expert knowledge of InterQual admission/medical necessity and documentation criteria
• Expert knowledge of Medicare, Medicaid and Commercial insurance requirements and financial reimbursement categories.
• Current knowledge of State and Federal regulations, Joint Commission standards, HIPAA regulations, and Medicare COP to ensure compliance with all regulatory bodies
• Current knowledge of Press Ganey and HCAHPS measures and performance tracking
• Excellent communication (oral and written), customer service and organizational skills
• Solid fiscal and analytical skills to develop/manage operational, capital and IT budgets and associated expense in achieving annual financial goals
• Outstanding leadership skills characterized by professional interpersonal dynamic, to include team building, staff mentoring and education, and relationship building with partners across the care continuum

Preferred Qualifications and Skills:

• Master’s degree in Health Care Administration, Business Management, Nursing or related health care field preferred
• Ability to listen and receive feedback openly and effectively
• Strong team approach to ensure collaboration across the care continuum
• Ability to multi-task, prioritize and manage workflow in a dynamic environment
• Remain current with best practices impacting clinical outcomes and reimbursement, making recommendations on new approaches to effective patient transitions of care
• Develops, supervises, and monitors departmental Quality Improvement activities
• Represents department at institutional meetings, activities, and to external agencies and organizations as assigned
• Promotes operational effectiveness and efficiencies to improve financial performance
• Interacts professionally with all internal and external stakeholders, maintaining leadership visibility
• Creates and maintains a positive and supportive work environment for all staff

Other duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

AGE AND DIVERSITY RELATED CRITERIA: Consistently treats patients, colleagues and visitors with the dignity and respect, while being sensitive to the differing needs of all age groups, backgrounds, characteristics and cultures.

ABILITY TO FULFILL JOB EXPECTATIONS: Must have the ability to the perform essential functions of the position, including required work hours, locations and physical demands, without posing a direct threat to the health and safety of themselves or other individuals in the work place, and with or without reasonable accommodation.

PHYSICAL DEMANDS: Physical demands refer to the level and duration of physical exertion generally required to perform critical tasks in support of critical job functions, for example - sitting, standing, walking, lifting, carrying, reaching, pushing, and pulling.