Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
will direct and manage departmental activities involved in utilization review,
appeals management and discharge planning to facilitate the case management
process and maximize reimbursement to the hospital. Must be able to navigate
through a wide variety of managed care contractual issues. Must have knowledge
of and familiarity with Interqual and Millman criteria.
Duties and Responsibilities:
1. 1. Reviews department clinical services and operations, and tracks case management activity. Identifies areas for performance improvement by examining productivity and workload within department. Directs, coaches, mentors and assesses staff in clinical case management service delivery.
2. 2. Ensures departments achieve institutional visions, goals and objectives by developing scope of service, establishing/maintaining effective relationships with physicians, and collaborating with other disciplines. Assesses goals and utilizes data to effect corrective action.
3. 3. Oversees activities of Care Managers.
4. 4. Presents regular productivity reports, and meets with Care Management staff on an individual basis to discuss targets and other issues of concern.
5. 5. Attends Joint Conference meetings with major payers.
6. 6. Develops relationships and seeks feedback from internal and external stakeholders regarding the implementation of department activities to garner satisfactory customer results.
7. 7. Emphasizes a collaborative approach and seeks to influence other services by focusing on patient processes.
8. 8. Develops and implements Utilization Review (UR) based on internal data collection, data received from external agencies, Physician
9. 9. Advisors and the Medical Director.
10. 10. Ensures Discharge Appeals functions are carried out within contractual, federal and state guidelines. Presents and reviews data relative to avoidable days, denials, length of stay and other key metrics to leadership
BSN in Nursing or health related field, Masters preferred
5 years Case Management and 6 years as clinical nurse. Previous supervisory experience in Case Management or related field.