Director of Case Management
The Director of Case Management is responsible for the coordination of the hospital-wide case management program. Oversees review of patient’s medical record to ensure proper utilization of hospital services. Assists case managers in providing timely coordination of care and discharge planning. Assures screening of all admissions to determine the appropriate level of care. Supervises case managers, overseeing the daily operations of the case management department to facilitate optimal financial and clinical outcomes. Additional responsibilities include fiscal planning and regulatory compliance. Analyzes current systems and variance to identify opportunities for improvement and works to promote quality of care through collaboration with members of the interdisciplinary team.
• Supervises Case Managers to ensure admission and continued stay reviews are conducted according to established procedures.
• Monitors inpatient statistics to ensure appropriate utilization of hospital resources.
• Carries patient load on a daily basis.
• Assists case managers in assessing any discharge needs to facilitate timely discharge.
• Coordinates denial management process.
• Oversees the provision of clinical information to private review organizations and maintains communication as required to obtain certification for the admission.
• Establishes effective working relationships with medical and hospital staff to educate and coordinate usage of resources and services as evidenced by appropriate length of stay.
• Maintains confidentiality of patient and department information.
• Prepares and submits required reports in a timely manner.
• Assures that all emergency admissions are precerted within 48 hours.
• Monitors Medicaid precertification requirements.
• Submits all retrospectively covered cases for precert numbers.
• Maintains current working knowledge of regulatory requirements/criteria.
• Analyzes denial and resource data to identify areas where changes are needed related to clinical, financial and patient outcomes.
• Co-chairs the Utilization Review Committee with the UR Physician and holds, at a minimum, quarterly meetings.
• Responsible for case management score card and other data collection, as appropriate or assigned.
Education and Training: RN licensure in the state where the hospital resides; BSN/MSN preferred. Certification in an approved Case Management Program preferred. Current BLS certification required.
Minimum Work Experience: Three to five years of case management experience required. Prior experience in IRF or LTACH setting preferred. Prior management experience preferred.
Required Knowledge, Skills, and Abilities:
• Knowledge of CMS Conditions of Participation Guidelines for Discharge Planning, Utilization Review, Documentation, Medicare Important Message, Face to Face Requirements, and Patient Choice
• Knowledge of Medicare, Medicaid, and Managed Care Products and the requirements of each payer to meet the various levels of care for post-hospital services
• Knowledge of CMS guidelines and use of level of care determination for inpatient and observation, CMS inpatient only list and other payer guidelines as required
• Knowledge of nursing, standards based practice, shared governance, organizational initiatives, in terms of theories and practices to serve as a resource and educator to others
• Knowledgeable regarding InterQual criteria for utilization review; strong knowledge of InterQual Level of Care criteria
• Advanced knowledge of utilization management principles, concepts, and strategies including admissions criteria, levels of care, and denials
• Advanced knowledge of commercial insurances, Medicare, Medicaid, and State/Federal regulations which impact utilization management
• Basic Microsoft Windows desktop application and navigation skills
• Strong organizational skills
• Effective leadership skills
• Effective written and verbal communication skills
PAM Health is committed to being the most trusted source for post-acute services in every community it serves by utilizing experienced and dedicated staff to provide high quality patient care and customer service. With over 44 Long Term Acute Care and Rehabilitation hospitals and 16 Outpatient Clinics currently in operation across the country, we are proud to offer services including comprehensive wound care, aquatic therapy, ventilator weaning, amputation treatment, pain management and much more.
Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.
We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at www.postacutemedical.com for a comprehensive look at how we're able to positively impact our local communities.
PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.