Manager Case Management
St. Dominic Hospital
CARE MANAGEMENT - 9740
The Manager of Care Management provides leadership of the utilization management process and facilitate appropriate transition of care for patient population. This position maintains operational oversight with 24-hour accountability for the assigned areas within Care Management.
Required Education and Experience
Minimum of 3 years experience in Case Management
RN with a Bachelor's Degree in Nursing
1. Demonstrates the ability to maximize financial outcomes associated with utilization management, resource management, delays, denials, medical necessity, and level of care determinations.
2. Coordinates and integrates quality review activities pertaining to medical necessity, level of care, resource utilization, system management, analysis, and evaluation to enhance operating efficiencies.
3. Analyze data, prepares variance reports, and monitors departmental and organizational records to ensure prudent resource and utilization management.
4. Evaluate treatment plans for over/under utilization of services as they relate to cost effective delivery of care to facilitate appropriate reimbursement through third party payor contracts.
5. Responsible for training new employees and on an ongoing basis in the application of medical necessity screening criteria (InterQual) to all staff assigned to utilization management activities.
6. Maintains relationships with payors to facilitate communication regarding processes to ensure timeliness of authorizations and reimbursements.
7. Educates all departmental staff responsible for medical necessity documentation in the requirements on an ongoing basis and maintains current on regulatory requirements to ensure compliance.
8. Responsible for interviewing, hiring, orienting, training, evaluating
performance and disciplinary activities as required in personnel management activities.
9. Coordinates and performs discharge planning activities and assists psychosocial needs with those providing social work.
10. Coordinates activities with ancillary departments and outside agencies
11. Collaborates with other hospital disciplines and agencies/facilities in the community in the development, implementation and accomplishment of the goals for optimum hospital and post-hospital care; monitors the discharge plan and evaluates progress toward plan goals, making any necessary changes, as indicated. Participates in Patient Care Conferences.
12. Manages, ensures competencies, and evaluates through auditing activities of assigned staff.
13. All other duties as assigned in the management of the daily departmental operations.
14. Directs and supervises functions and activities in Care Management in the absence of the Director of Care Management