ESSENTIAL VALUES-BASED, LEADERSHIP AND MANAGEMENT COMPETENCIES:
Demonstrates competencies in line with the five core values that are the foundation of all activities performed by employees in order to achieve the Mission of Artesia General Hospital
- Servant Leadership – Leading by serving others with compassion and humility.
- Excellence – Striving for the highest quality in all we do.
- Respect – Treating everyone with dignity and kindness
.• Virtuousness – Acting with honesty, integrity, and accountability.
- Innovation – Embracing new ideas to improve care and outcomes.
- Community – Fostering collaboration to meet the needs of those we serve.
- Education – Promoting learning and professional development.
ESSENTIAL FUNCTIONS:
- Directs the daily operations of case management, utilization management, discharge planning, social services, and care transitions.
- Establishes department goals, workflows, performance expectations, and accountability measures.
- Provides supervision, coaching, education, and performance evaluation for case management and social services staff.
- Ensures adequate coverage for utilization review, discharge planning, payer communication, and high- risk patient needs.
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Determines Patient medical eligibility, qualifying diagnosis, and determines Medicare/Managed Care eligibility based on skilled services provided
- Develops, reviews, and maintains departmental policies and procedures.
- Promotes effective communication and collaboration among case management staff, nursing, physicians, ancillary departments, and hospital leadership.
- Assists with departmental budgeting, staffing, productivity, and resource allocation.
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Identifies and plans strategies to reduce in-patient length of stay and resource consumption.
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Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
- Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.
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UTILIZATION MANAGEMENT and MCG
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Oversees the consistent and appropriate application of MCG guidelines for admission, level-of-care, continued-stay, and discharge-readiness reviews.
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Ensures MCG criteria are used as a clinical decision-support tool and not as a substitute for physician judgment, applicable regulations, payer requirements, or the patient’s individual clinical circumstances.
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Reviews inpatient, observation, and outpatient cases to support appropriate patient-status recommendations.
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Ensures timely initial and concurrent reviews, payer notifications, authorizations, and clinical updates.
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Escalates cases that do not clearly meet MCG criteria or require additional physician documentation.
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Collaborates with attending physicians and hospital leadership regarding inpatient versus observation status.
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Facilitates secondary physician review or physician-advisor review when medical necessity or patient status remains unclear.
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Supports compliance with the Medicare Two-Midnight Rule and other applicable CMS patient-status requirements.
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Ensures required Medicare notices are delivered accurately and timely, including the Medicare Outpatient Observation Notice and other applicable beneficiary notices.
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Monitors the use of MCG and identifies educational needs, inconsistent application, and workflow gaps.
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Maintains staff competency in the hospital’s current licensed MCG content and documentation requirements.
PATIENT STATUS and MEDICAL NECESSITY
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Reviews admissions and continued stays for medical necessity, intensity of service, severity of illness, and appropriate level of care.
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Identifies cases at risk for incorrect status, noncoverage, delayed authorization, or denial.
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Communicates medical-necessity concerns promptly to physicians and appropriate hospital leaders.
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Facilitates status changes when supported by the patient’s clinical condition, physician order, regulatory requirements, and hospital policy.
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Monitors short inpatient stays, extended observation stays, avoidable admissions, and potentially preventable readmissions.
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Ensures that patient-status determinations and changes are properly documented and supported in the medical record.
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Collaborates with health information management, clinical documentation integrity, patient financial services, and revenue-cycle staff to improve documentation and reimbursement integrity.
DISCHARGE PLANNING and CARE COORDINATION
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Ensures discharge planning begins at admission and is reassessed throughout the hospitalization.
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Oversees the completion of initial assessments and the identification of medical, psychosocial, financial, functional, behavioral, and post-acute care needs.
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Leads interdisciplinary efforts to develop safe, timely, and patient-centered discharge plans.
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Coordinates placement and services involving skilled nursing facilities, rehabilitation facilities, long-term acute-care hospitals, home health, hospice, durable medical equipment, behavioral health, transportation, and community resources.
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Ensures patients and families are actively involved in discharge planning and receive understandable information regarding available options.
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Addresses barriers that delay discharge, including placement, transportation, medication access, insurance authorization, housing, caregiver availability, and equipment needs.
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Facilitates complex case conferences and multidisciplinary care-planning meetings.
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Supports safe transitions of care and communication with post-acute providers and primary-care clinicians.
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Works to reduce avoidable readmissions and prevent gaps in care following discharge.
LENGTH of STAY and THROUGHPUT
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Participates in or leads daily interdisciplinary patient progression and discharge-planning rounds.
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Reviews each patient’s expected date of discharge, barriers to progression, outstanding tests or consultations, and post-acute needs.
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Identifies avoidable delays and escalates unresolved barriers to the appropriate leader or physician.
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Collaborates with nursing, medical staff, ancillary departments, and hospital leadership to improve patient flow.
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Monitors observation length of stay, inpatient length of stay, avoidable days, discharge order-to-departure time, and delayed discharges.
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Develops corrective action plans when performance does not meet organizational goals.
DENIAL PREVENTION and MANAGEMENT
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Oversees the identification, tracking, review, and response to clinical and medical-necessity denials.
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Ensures payer requests for clinical information are completed accurately and within required time frames.
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Coordinates peer-to-peer reviews, reconsiderations, and appeals with physicians, payers, and revenue-cycle staff.
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Performs root-cause analysis of denials and develops strategies to prevent recurrence.
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Educates physicians and staff regarding documentation patterns that contribute to denials or payment risk.
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Tracks denial trends by payer, reason, provider, service line, patient status, and financial impact.
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Collaborates with finance and revenue-cycle leadership to improve authorization processes and reduce preventable write-offs.
REGULATORY and ACCREDITATION COMPLIANCE
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Maintains compliance with applicable CMS Conditions of Participation, Medicare requirements, state and federal regulations, hospital policies, and accreditation standards.
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Supports compliance with patient-choice, discharge-planning, beneficiary-notification, and utilization-review requirements.
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Participates in the hospital’s Utilization Review Committee and prepares required utilization data and case reviews.
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Maintains confidentiality and complies with HIPAA and other patient-privacy requirements.
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Ensures department records, case reviews, notices, and supporting documentation are complete and audit-ready.
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Participates in regulatory surveys, payer audits, internal audits, and corrective-action planning.
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Maintains current knowledge of changes in reimbursement, utilization management, discharge planning, and payer requirements.
QUALITY and PERFORMANCE IMPROVEMENT
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Develops and monitors department performance indicators, including:
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Inpatient and observation conversion trends
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Observation stays exceeding established targets
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Initial and concurrent review timeliness
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Authorization completion
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Inpatient and observation length of stay
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Avoidable days and discharge delays
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Readmissions
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Medical-necessity and authorization denials
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Appeal outcomes
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Discharges before noon or other established throughput goals
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Referral and placement turnaround times
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MCG review compliance
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Medicare-notice compliance
- Reports performance trends, risks, and corrective actions to hospital leadership and applicable committees.
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Uses case reviews and data analysis to identify opportunities for improved quality, efficiency, documentation, and financial performance.
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Leads performance-improvement initiatives related to utilization, care transitions, patient flow, and denial prevention.
MEDICAL STAFF COLLABORATION
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Develops effective working relationships with attending physicians, emergency department providers, hospitalists, surgeons, and other medical staff members.
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Provides education regarding MCG, patient status, medical necessity, documentation, length of stay, and payer requirements.
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Communicates physician-specific trends respectfully and objectively.
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Escalates unresolved concerns through the established chain of command.
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Supports physician-to-physician discussions and peer-to-peer reviews when required.
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Serves as a resource to the medical staff regarding utilization-management and discharge-planning requirements.
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ADDITIONAL RESPONSIBILITIES:
REQUIRED QUALIFICATIONS:
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Bachelor’s degree in nursing required.
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Current, unrestricted Registered Nurse license in the state of New Mexico or eligibility for licensure.
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Minimum of five years of clinical nursing experience in an acute-care setting.
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Minimum of three years of case management, utilization review, discharge planning, or related experience.
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Minimum of two years of leadership or supervisory experience preferred.
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Demonstrated experience using MCG or comparable evidence-based utilization-management criteria.
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Knowledge of inpatient, observation, and outpatient status requirements.
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Knowledge of CMS regulations, the Medicare Two-Midnight Rule, utilization-review requirements, discharge-planning requirements, and beneficiary notices.
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Experience with payer authorization, concurrent review, denials, appeals, and peer-to-peer processes.
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Proficiency with electronic health records, utilization-review systems, data analysis, and Microsoft Office applications.
KNOWLEDGE, SKILLS and ABILITIES:
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Strong working knowledge of MCG guidelines and utilization-management principles.
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Ability to interpret clinical information and communicate medical-necessity concerns clearly.
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Strong leadership, coaching, and performance-management skills.
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Ability to build collaborative relationships with physicians and interdisciplinary teams.
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Excellent critical-thinking, problem-solving, organizational, and prioritization skills.
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Ability to manage multiple complex cases and operational priorities in a small-hospital environment.
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Understanding of reimbursement, payer contracts, authorization requirements, and denial risk.
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Ability to analyze performance data and translate findings into measurable improvement plans.
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Strong verbal, written, and presentation skills.
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Ability to manage sensitive situations professionally and maintain patient confidentiality.
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Commitment to patient-centered care, regulatory compliance, ethical practice, and responsible resource utilization.
The Director of Case Management will be expected to:
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Establish a reliable daily utilization-review and discharge-planning process.
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Ensure all admissions receive timely medical-necessity and patient-status review.
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Improve the accuracy of inpatient and observation status determinations.
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Reduce extended observation stays and avoidable inpatient days.
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Improve physician documentation supporting medical necessity.
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Strengthen the consistent use of MCG across the organization.
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Reduce preventable clinical and authorization denials.
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Improve discharge planning, care transitions, and interdisciplinary communication.
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Maintain department readiness for regulatory, accreditation, and payer audits.
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Provide hospital leadership with accurate and actionable case-management performance data.
AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.
INFORMATION MANAGEMENT: Treats all information and data within the scope of the position with appropriate confidentiality and security.
RISK MANAGEMENT/QUALITY MANAGEMENT/SAFETY: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.
ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.
