Director, Case Management, Full Time

Hialeah Hospital•Hialeah, FL

3d•Onsite

About The Position

The individual in this position has overall responsibility for hospital utilization performance improvement and operational management of the Case Management Department. The goal is to promote effective use of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services. 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 in the right sequence and at the appropriate level of care; Compliance with state and federal regulatory requirements, TJC accreditation standards and Hialeah Hospital policy; and Education provided to physicians, patients, families and caregivers. The individual's responsibilities include managing department operations to assure effective throughput and reimbursement for services provided, leading the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, ensuring medical necessity review processes are completed accurately and in compliance with CMS regulations and Hialeah Hospital policy, ensuring timely and effective patient transition and planning to support efficient patient throughput, implementing and monitoring processes to prevent payer disputes, developing and providing physician education and feedback on hospital utilization, and ensuring compliance with state and federal regulations and TJC accreditation standards.

Requirements

Bachelor's Degree
BLS Certification Required
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
Computer literacy

Nice To Haves

Master's Degree strongly preferred
At least two 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
Business planning experience preferred

Responsibilities

Manage department operations to assure effective throughput and reimbursement for services provided.
Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement.
Ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and Hialeah Hospital policy.
Ensure timely and effective patient transition and planning to support efficient patient throughput.
Implement and monitor processes to prevent payer disputes.
Develop and provide physician education and feedback on hospital utilization.
Ensure compliance with state and federal regulations and TJC accreditation standards.
Other duties as assigned.
Complete Hialeah Hospital InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better.
Complete and demonstrate competency in using the Hialeah Hospital Case Management documentation system within 30 days of hire.
Attend hospital orientation.
Work with regional Performance Management and Innovation (PMI) Case Management leader to complete PE Director of Case Management orientation within 90 days of hire.