Care Management Manager

Johnson County Hospital•Tecumseh, NE

About The Position

The Care Management Manager is responsible for the operational and clinical oversight of the hospital's Care Management program, including Utilization Review (UR), care coordination, discharge planning, and payer medical necessity compliance. This role ensures compliance with CMS Conditions of Participation, supports appropriate patient status determination, collaborates with medical staff, and partners with Revenue Cycle and Patient Access to reduce denials and support efficient patient throughput. This position provides leadership to care management staff and serves as a key liaison between clinical services, medical staff, quality, compliance, and revenue cycle operations.

Requirements

Current Registered Nurse (RN) license in the state of practice
Experience in Utilization Review, Case Management, or Care Coordination
Knowledge of CMS Conditions of Participation and Medicare regulations
Bachelor's degree in Nursing or related healthcare field (preferred)

Nice To Haves

Master's degree in Nursing, Healthcare Administration, or related field
Certification in Case Management or Utilization Review (CCM, ACM, CPUR, or equivalent)
Experience in a Critical Access Hospital or rural healthcare setting

Responsibilities

Oversees the hospital's Utilization Review program in compliance with CMS Conditions of Participation, Medicare regulations, and payer requirements.
Ensures timely and accurate medical necessity reviews.
Monitors patient status determination (inpatient vs. outpatient/observation) and facilitates appropriate escalation to providers.
Coordinates and prepares cases for Utilization Review Committee meetings; tracks outcomes and follow-up actions.
Ensures physician advisor involvement when indicated.
Oversees care coordination and discharge planning processes to support safe, timely, and appropriate transitions of care.
Collaborates with nursing, providers, therapy services, and ancillary departments to remove barriers to discharge.
Ensures compliance with discharge planning regulations, including patient choice and post-acute care referrals.
Collaborates with billing and revenue cycle to support timely prior authorization and concurrent review processes.
Assists with clinical documentation and medical necessity appeals when required.
Participates in payer communications related to medical necessity, level of care, and length-of-stay reviews.
Analyzes utilization trends, denials data, and length-of-stay metrics to identify opportunities for improvement.
Partners with other departments as necessary to reduce avoidable denials related to medical necessity or documentation.
Develops and implements action plans to address identified gaps.
Ensures Care Management activities align with CMS Conditions of Participation, accreditation standards, and hospital policies.
Participates in Quality Assurance and Performance Improvement (QAPI) initiatives related to utilization, throughput, and care coordination.
Assists with survey readiness, mock surveys, and regulatory audits.
Provides direct supervision, coaching, and performance management of Care Management staff.
Ensures staff competency through orientation, ongoing education, and annual evaluations.
Develops and maintains department policies, procedures, and workflows.
Educates providers and staff on medical necessity requirements, documentation standards, and patient status guidelines.
Promotes a collaborative approach to utilization management and care coordination.