Description
Duties and Responsibilities
- Oversight of the Facility’s Case Management team to ensure compliance with standards of practice and other regulatory requirements related to care management and utilization review.
- Develop and foster effective collaboration between Case Management Departments, Medical Staff, corporate and facility leaders to ensure an integrated approach to providing care while fulfilling the hospital's goals and objectives.
- Display an ability to work effectively within the health system's decision making and organizational structures.
- Work closely with providers as well as internal and external physician advisors for utilization review and management activities
- Coordinate all UM Committee activities to ensure compliance with meeting frequency and documentation of activity and outcomes
- Work collaboratively with Revenue Cycle teams and participates in task force meetings related to medical necessity audits and denials.
- Participate in appeals processes and work collaboratively with vendors to ensure the effectiveness and timeliness of appeals
- Analyze length of stay and readmissions data and incorporate measures with Operations team members, Corporate Case Management Directors and other facility leaders to ensure goals are met
- Introduce evidenced based practices geared to improve case management and transitions
- Conduct regular staff meetings to review pertinent Federal and State regulatory requirements, emerging internal and external trends, and provide general training for staff
Qualifications
II. Position Requirements :
A.Licensure / Certification / Registration :
Applicants with the following licensure may be considered : Oklahoma RN
B.Education : BSN preferred, Registered nurse is required. Certification in Case Management or Utilization Review is preferred
Skills
- Demonstrated leadership and complex organizational management skills
- Excellent management, problem solving, team building & organizational skills
- Familiarity with Federal & State regulations related to case management discharge planning.
- Knowledge of integrated discharge planning practices and resources available to patients
- Demonstrated knowledge of RACs, MACs and the Medicare appeals process
- Ability to work with Administration, Physicians, and staff in multiple settings
- Ability to compile reports and interpret data
- Ability to prepare and administer presentations
Ability to interpret and apply InterQual criteria
Experience : A minimum of 5 years experience in case management, discharge planning, and / or utilization review in an inpatient acute care setting.
Strong clinical background is preferred.
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