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 Hospital policy
Education provided to physicians, patients, families and caregivers
The individual's responsibilities include the following activities across HSA hospitals: a) oversee department operations to assure effective throughput and reimbursement for services provided, b) lead the implementation and oversight of hospital Utilization Management Plans using data to drive hospital utilization performance improvement, c) ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and HSA 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) ensure compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.
Position Qualification: (Training, Education, Experience, Skills and Abilities)
Required qualifications include an active Registered Nurse license with at least 5 years acute hospital case management, leadership experience preferred. MSN preferred. Accredited Case Manager (ACM) preferred. McKesson InterQual® experience preferred. Five years acute hospital case management experience preferred. 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.
Training Requirement:
Must complete InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Case Management documentation system within 30 days of hire. Attendance at hospital orientation is required. Must work with regional Performance Management and Innovation (PMI) Case Management leader to complete PE Director of Case Management orientation within 90 days of hire.
Primary Information, Tools and Systems Used:
Patient data – hospital admission, discharge, transfer system
Healthcare staff documentation related to patient care
Regulatory and payor requirements
Allscripts Care Management System
McKesson Care Enhance Review Manager (CERMe) InterQual system
Crimson
Clinical data interface and secure faxing
Patient Medical Record including Cerner and HPF
Hospital Specific Clinical Software
Enterprise Reporting: Decision Support reports, PMI reports
Care Discovery
Position Control
Communication Skills:
Ability to effectively communicate in writing and orally with all levels of the organization
Your email job alert is now active!