Case Management Manager
2 weeks ago
EducationBachelor's degree in Nursing Required orMaster's degree in Social Work Required Master's degree in Nursing, Healthcare Administration or Business for the BSN holder Preferred Experience5-7 years in Case Management and/or utilization review experience Required Prior experience in management or administrative position Preferred Licenses and CertificationsRN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia Required orLic Independent Clin Soc Wrk - LICSW in the District of Columbia Required CM - Case Management within 1-1/2 Yrs Required Knowledge, Skills, and AbilitiesKnowledge of payer requirements, discharge planning regulations, accreditation standards, data collection, analysis, and data presentation.Knowledge of MCG, Allscripts and information systems.Manages the daily operations of the department by maintaining appropriate staffing levels and assignments. Refers to the current census report at the beginning of the shift and makes staffing changes if warranted. Monitors patient volume/census and case complexity/acuity fluctuations, reassigning staff as appropriate.Under the direction of the Director of Case Management, manages department staff. Is involved in orientation, training and mentoring and assessing competencies for all Discharge Planners in the Department; and completing annual and interim performance reviews.Ensures case management presence and participation at daily care coordination rounds.Establishes work procedures, writes individual hospital policies and guidelines. Monitors for compliance, under the guidance of the Director of Case Management.Works collaboratively with Peer Managers, and the Senior/Complex Team personnel to problem solve complex cases requiring care coordination, utilization management and discharge planning assistance.Serves as a resource and role model for the department staff including but not limited to fielding questions, coaching, mentoring, educating, and providing support to the staff.Initiates employee progressive discipline and counseling procedures for performance, time, and attendance issues, etc. seeking assistance from the Director as needed.Participates in weekly Leader Rounds on staff. Provides support and education on a one-to-one level and is actively visible to the staff on their units.Provides outreach and professional partnering with external vendors, post acute and community facilities, healthcare organizations, insurance companies etc.Escalates issues to the department director (e.g. physician, complex cases, legal, regulatory, complaints, risk, safety, patient and family complaints and concerns).Assists with maintaining accreditation and regulatory compliance by ensuring standards and regulation are followed during daily operations.Participates in hospital and/or community committee as determined by Clinical Resource Management Director/Administration.Monitors key performance indicators to ensure that objectives are met. These include clinical assessments of patients for care coordination, utilization management, discharge planning, and post acute evaluation.Develops utilization and discharge planning case management policies and procedures, standards, and competencies for performance.Reports on the case management dashboard key indicators and prepares reports as requested.Establishes and promotes relationships with clinical team members, physician advisor and individual physicians to promote care coordination and effective discharge planning.Contributes to the development of physician strategy as related to documentation and resource management.Promotes and supports a customer service-oriented environment by responding to patient and/or physician concerns in a timely manner by serving as a facilitator in problem-solving related to social services when requested and/or needed.If applicable to incumbent in this job, establishes and promotes positive and collaborative working relationships with primary players in proper prevention of denials and management of the appeals process, including, but not limited to central business office, coding, HIM, contracting, outside vendors, Managed Care personnel, outpatient appeals personnel, CRM staff and physician advisors, clinical team members physicians and insurers.If applicable to incumbent in this job, provides project management for appeals/denials activities.If applicable to incumbent in this job, works collaboratively with CRM Director and CRM Managers to problem solve core issues which cause denials and provide training around prevention as needed.If applicable to incumbent in this job, acts as a repository for denials data. Analyzes and reports on the appeals/denials dashboard key indicators and prepares reports.Demonstrates a professional attitude and motivation open working relationship with staff and other departments utilizing appropriate resources in the chain of command.
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