Description:

Summary

The individual in this position has overall responsibility for hospital utilization management, transition management and operational management of the Case Management Department in order to promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with all state and federal regulations related to case management services.
This position integrates national standards for case management scope of services including:
Utilization Management supporting medical necessity and denial prevention
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to physicians, patients, families and caregivers

Responsibilities

The individual's responsibilities include the following activities:

• Manage department operations to assure effective throughput and reimbursement for services provided
• Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement
• Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and Tenet policy
• Ensure timely and effective patient transition and planning to support efficient patient throughput
• Implement and monitor processes to prevent payer disputes
• Develop and provide physician education and feedback on hospital utilization
• Participate in management of post-acute provider network
• Ensure compliance with state and federal regulations and TJC accreditation standards, and) other duties as assigned.

Qualifications:

Education

Required:
Preferred: BS/BSN preferred (BSN required if Magnet Hospital). MSN, MBA or MHA preferred.

Experience

Required: Two (2) years in Case Management Leadership.
Preferred: Five (5) years acute hospital case management experience preferred. Business planning experience preferred. McKesson InterQual® experience preferred.

Certifications

Required: Registered Nurse license. Preferred Accredited Case Manager (ACM).

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