Summary

The Group Director Case Management is responsible for executing the hospital's organizational case management strategic plan across multiple hospitals. They are a leader, mentor, consultant, and subject matter expert regarding case management regulations and standards. 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: Lead and facilitate group hospital Directors of Case Management performance for Level of Care, Length of Stay, and Payer Authorizations Establish goals and objectives that support overall strategic plans of the Case Management and Utilization Review strategy Lead Group hospital Case Management and Utilization Review operations for cost-effective and clinically sound care delivery including the hospital's Case Management model, staffing and skill mix, complex Case Management, and centralized utilization review Participate in new hospital Director of Case Management selection and lead the orientation and onboarding processes Maintain objectivity in decision making, utilizes facts to support decisions Anticipate and responds to problems and risks Communicate effectively with all levels in the organization and with internal / external customers Direct, support, and coach direct reports Develop "experts" and "expertise" throughout the department and seeks employee input Minimize staff turnover Lead implementation and monitoring of the hospital's Case Management policy and regulatory requirements Review weekly Case Management Scorecard Continuing Care (CC) and Utilization Review (UR) metrics, Observed / Expected Length of Stay, Authorizations and Downgrades Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement Manage department operations to ensure effective throughput and reimbursement for services provided Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and the hospital's 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 Other duties as assigned Qualifications:

Education: Required: Bachelor's degree in business, Nursing or Health Care Administration for RN or Master's in Social Work for MSW. Preferred: Advanced degree in business, nursing and/or healthcare administration, health science or related discipline. Experience: Required: Five (5) years of acute hospital case management or healthcare leadership experience. Preferred: Multi-site hospital case management leadership experience, business planning and project management experience preferred. License/Certificates/ Credentials: Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered. Preferred: Accredited Case Manager (ACM) Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem-solving skills and computer literacy. Business planning experience preferred. PHYSICAL DEMANDS: Lift/position up to 25 lbs. Push/pull up to 25 lbs. of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending Manual dexterity, mobility, touch, auditory to perform all the related duties of the position WORK ENVIRONMENT: Individual works in a fast paced clinical and office environment Pay Range: $72.00 - $115.21 hourly Individual wages are determined based upon a number of factors including, but not limited to, an individual's qualifications and experience The hospital complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

Responsibilities

Serve effectively in their current role as hospital DCM. Lead and facilitate group hospital DCMs performance for Level of Care, Length of Stay and Payer Authorizations; Lead group hospital case management operations for cost-effective and clinically sound care delivery including the hospital's case management model, staffing and skill mix, complex case management, and centralized utilization review; Participate in new hospital DCM selection and lead the orientation and onboarding process; Lead implementation and monitoring of the hospital's case management policy and regulatory requirements. Weekly Case Management Scorecard Continuing Care (CC) and Utilization Review (UR) metrics; Observed/Expected Length of Stay; Authorizations and Downgrades. The individual's responsibilities include the following activities:

a) manage department operations to assure effective throughput and reimbursement for services provided,

b) lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement,

c) ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and the hospital's policy,

d) ensure timely and effective patient transition and planning to support efficient patient throughput,

e) implement and monitor processes to prevent payer disputes,

f) develop and provide physician education and feedback on hospital utilization,

g) participate in management of post-acute provider network,

h) ensure compliance with state and federal regulations and TJC accreditation standards, and

i) other duties as assigned.

Qualifications

Education:

Required: Bachelor's degree in Business, Nursing, Social Work, or Health Care Administration

Preferred: Advanced degree in business, nursing, and/or healthcare administration, health science, or related discipline

Experience:

Required: 5 years of hospital Case Management Leadership

Preferred: 5 years of acute hospital case management leadership multi-site experience. Business planning and project management experienced.

Certifications:

Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.

Preferred: Accredited Case Manager (ACM)

Physical Demands:

Lift/position up to 25 lbs. Push/pull up to 25 lbs. of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position.