VP - Case Management

Ochsner Health•New Orleans, LA

About The Position

This position provides leadership and direct oversight for Case Management and Social Services. The VP sets the overall direction for assigned areas, develops plans to achieve goals and operating standards, and works collaboratively with clinical and business functions to align organizational goals and review performance. The role leads Case Management to ensure regulatory compliance and promote a patient-centered approach that supports patient experience goals. The position oversees utilization management, discharge planning, precertification and denials management, retrospective Medicaid, medical necessity denials, and care transitions across the organization. It sets strategy, policies, processes, procedures, training and development expectations, and goals for monthly operating reviews. The VP collaborates with organizational partners, supports leadership development and staff retention, and ensures teams maintain compliance and pursue continuous improvement while working collaboratively with medical staff. The role requires a master’s degree in business, nursing, or another healthcare-related field and 15 years of experience in Case Management or a related field, including progressive management experience and experience with insurance precertification, utilization management, and DRG management. An RN license in the state of practice and a Case Management certification are preferred. This is sedentary work, generally involving sitting with occasional walking or standing and exertion of up to 10 pounds occasionally. The role normally has no exposure to blood, body fluid, or tissue and no occupational risk for communicable disease exposure. Work in a healthcare setting may involve occupational risk of exposure to hazardous medications or waste, depending on duties. The description notes that duties may change and may include other related responsibilities as assigned.

Requirements

Master’s degree in business, nursing, or another healthcare-related field.
15 years of experience in Case Management or a related field.
Progressive management experience, including frequent involvement with senior management, physicians, and outside care providers.
Experience with insurance precertification, utilization management, and DRG management.
Proficiency with computers, software, and web-based applications, and willingness to learn applications used by the Case Management team.
Excellent verbal and written communication skills, including the ability to present information clearly and professionally to different audiences.
Ability to present performance and opportunities to leadership groups across the organization.
Excellent interpersonal and conflict-management skills, including the ability to relate to executive management, physicians, professionals, and business community leaders.
Ability to collaborate and build teams aligned with strategic purpose.
Knowledge of regulatory and compliance issues and ability to learn local payor rules that influence reimbursement.
Ability to review financial performance, including department financial statements, revenue-cycle payor denials, and opportunities related to appropriate patient status levels.
Ability to meet the physical demands of sedentary work, including occasionally exerting up to 10 pounds and sitting most of the time, with occasional walking or standing.

Nice To Haves

RN license in the state of practice.
Certification in Case Management, such as ACM, CCM, HCQM, or CMAC.

Responsibilities

Provides leadership and direct oversight for Case Management and Social Services.
Oversees utilization management, discharge planning, precertification and denials management, retrospective Medicaid, medical necessity denials, and care transitions for the organization.
Develops strategy to drive continuous improvement and establishes expectations for teams.
Sets the direction for assigned areas and implements organizational policies, processes, and procedures.
Helps set system training and development programs so staff and leaders understand their roles and performance expectations.
Collaborates with Physician Advisors, Emergency Medicine, Hospital Medicine, Nursing, Compliance, Revenue Cycle, Finance, Post-Acute Care, and other medical specialties to align goals and performance reviews.
Oversees leadership development and staff-retention strategy, including opportunities for internal promotion and staff engagement in department goals.
Prepares an annual Case Management strategy and establishes goals for review in monthly operating reviews.
Ensures regulatory compliance, continuous improvement, and collaborative relationships with medical staff.
Ensures Case Management teams use a patient-centered approach and focus on patient experience goals within their influence.
Adapts communication and services to patient populations, respecting privacy, seeking permissions, and adjusting explanations and communication style as appropriate.
Remains knowledgeable about applicable laws, accreditation standards, and regulatory requirements and ensures compliance.
Reports known or suspected unethical or questionable conduct and patient or employee safety, privacy, or other compliance concerns.
Performs other related duties as assigned.