The Director of Case Management leads a collaborative case management effort by coordinating the care and services of patient populations at the assigned facility. Provides clinical leadership for the care management team by serving as an educator, role model, patient advocate, and change agent to achieve optimal clinical, financial, and resource outcomes. Oversees daily team activities and provides strong leadership through training, coaching, teaching and managing assigned teams. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
BSN or BS in healthcare-related field.
Five (5) years’ clinical nursing experience required.
Two (2) years’ experience in care coordination, case/care management, utilization/resource management, quality management or transitions of care required.
Demonstrated leadership skills gained through previous supervisory/management experience.
Current license as an RN in the state where work is performed, or compact license.
Certified Case Manager (CCM) or Accredited Case Manager (ACM).
Master’s degree is preferred.
Acute care experience preferred.
Must pass the CCM or ACM certification upon qualification for the exam, with the certification complete within one year from date in the job.
Working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Strong understanding of pre-acute and post-acute venues of care and post-acute community resources.
Demonstrates advanced conflict resolution and problem solving skills for timely resolution of issues.
Communicates clearly and professionally in both oral and written communication.
Demonstrated ability to develop and maintain working relationships with physicians and work collaboratively with health professionals at all levels to achieve established goals.
Knowledge of quality improvement tools and metrics to assess and manage case management goals.
Understanding of regulatory/compliance requirements such as UM/URAC and CMS conditions of participation.
Demonstrated excellent facilitation skills.
Strong organizational and time management skills as evidenced by capacity to prioritize multiple tasks and roles.
Intermediate to advanced computer skills; experienced with Microsoft Word and Excel. Knowledge of EMR systems and case management software and tools.
Ability to use initiative in decision-making, independent judgment, and critical thinking skills.
Key Job Responsibilities
Provides clinical guidance and supervision to all case management programs, based on accepted principles of nursing, social work, and case management practice.
Provides leadership to the interdisciplinary team to achieve optimal outcomes through the tools of care management.
Collaborates with stakeholders to continually streamline, standardize, and systematically implement best practice case management processes, including interfaces with revenue cycle.
Develops and implements case management programs, including utilization review, intake, and discharge planning.
Manages and monitors department activities to evaluate the productivity and quality of programs and processes in order to identify potential improvements and ensure maximum performance.
Develops and administers budgets for operational areas, authorizes expenditures, and monitors budget and other financial indicators. Assists in the development and implementation of plans to control costs and improve department operations.
Develops and maintains professional networks and relationships with hospitals, physicians, community resources, and other providers to promote continuity and quality of care.
Uses a collaborative approach with physicians and the multidisciplinary team to facilitate care and eliminate barriers for the designated case load. Ensures that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Seeks care plans that balance clinical and financial concerns with the family’s needs and the patient’s quality of life.
Uses data to drive decisions and plan/implement improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data.
Initiates and leads the development, implementation, evaluation, and revision of clinical pathways.
Ensures that policies and procedures are developed and enforced in alignment with standards of patient care and regulatory bodies, and that the core components of case management processes are followed.
Works in collaboration with other key stakeholders to remain current on regulatory requirements. Participates in the development of standardized processes to fulfill compliance with all CMS and regulatory agencies’ statutes/standards specific to utilization management.
Serves as a resource to the corporate and facility Revenue Cycle teams as well as Corporate Compliance for any/all denials including all pre and post pay audits related to utilization management. Serves as an active participant in the appeals process.
The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
Must have good balance and coordination.
The physical requirements of this position are: medium work - exerting up to 50 lbs. of force occasionally and/or up to 25 lbs. of force frequently.
The Associate is required to have close visual acuity including color, depth perception, and field of vision to perform an activity, such as assessing patients, preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
Occasional invasive and non-invasive patient contact.
Exposure to patient body fluids as well as exposure to hazardous or poisonous materials.
Ability to react quickly to emergency situations.
Occasional travel to other facilities.