RN Manager Care Management
Location: St. Dominic Hospital
Department: CARE MANAGEMENT - 9740
Employment Type: Full Time 80
Other Shift Details:
Job Code: 8695
Manager of Care Management
The Manager of Care Management provides leadership of the utilization management process and clinical documentation integrity program. This position maintains operational oversight with 24 hour accountability for the assigned areas within Care Management.
Required Education and Experience
RN with a Bachelor's Degree in Nursing
Minimum of 3 years experience in Case Management
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 in an effort to enhance operating efficiencies.
3. Analyze data, prepares variance reports, and monitors departmental and organizational records in order 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 in order to ensure compliance.
8. Responsible for interviewing, hiring, orienting, training, evaluating
performance and disciplinary activities as required in personnel management activities.
9. Provides current and ongoing education on the clinical documentation integrity program to ensure capture of documentation in the medical record to promote increased reimbursement practices.
10. Tracks and trends data for the clinical documentation integrity program to analyze financial trends and opportunities to focus process improvement efforts.
11. Manages, ensures competencies, and evaluates through auditing activities of assigned staff.
12. All other duties as assigned in the management of the daily departmental operations.