Managed Care Lead Case Management

About the role

The Lead Case Manager assists with daily oversight of the hospital census to ensure effective and timely transitions of care, oversees regulatory compliance processes and staff adherence to policies, develops collegial relationships with interdisciplinary team leads, educates case managers on health plans and regulatory changes, provides feedback to staff to support coordinated care, monitors length of stay to secure post‑acute care authorizations, and ensures adherence to CMS Conditions of Participation for discharge planning and other regulatory requirements.

Responsibilities

• Assist with daily oversight of hospital census to ensure effective and timely transitions of care.
• Oversee regulatory compliance processes and staff compliance with policies and procedures.
• Develop collegial relationships with interdisciplinary team leads.
• Educate case managers regarding health plans and regulatory changes related to transitions of care.
• Provide feedback to staff to support well‑coordinated care amongst the interdisciplinary team and post‑acute providers.
• Monitor length of stay to assist the team in securing authorization for patient’s post‑acute care through collaboration and communication with health plan case managers and discharge planners.
• Adhere to CMS Condition of Participation for Discharge Planning and other regulatory requirements.
• Participate in peer review, professional development activities and act as a preceptor.
• Provide patient and family education throughout the care of the patient.
• Participate in activities aligned with the Magnet Model.
• Comply with organizational quality dashboard benchmarking goals.
• Make daily work assignments for each Case Manager.
• Attend Revenue Cycle meeting monthly.
• Utilize experience and in‑depth knowledge to effectively modify and document changes in nursing care and/or the plan of care to address patient care problems and keep the primary care provider updated.
• Assess health needs of patients using specialized knowledge and skills and anticipate the outcome of interventions.
• Collaborate with the Utilization Review Nurse to expedite discharges and screen admission requests.
• Perform chart review and quality assessments as directed.
• Identify inappropriate bed utilization and quality of care problems and refer them to the Utilization Management physician advisor.

Qualifications

• Bachelor’s degree in Nursing.
• Five years of experience in case management.
• Five years of clinical experience in an acute care facility.

Requirements

• Registered Nurse License.
• BLS or ACLS Certification.

Skills

• Knowledge of health plans and regulatory changes related to transitions of care.
• Ability to develop collegial relationships with interdisciplinary team leads.
• Skill in monitoring length of stay and securing post‑acute care authorizations.
• Proficiency in providing patient and family education.
• Ability to participate in peer review, professional development, and act as a preceptor.
• Experience with quality dashboard benchmarking and Magnet Model activities.
• Capability to make daily work assignments and attend revenue cycle meetings.
• Competence in chart review, quality assessments, and collaborating with Utilization Review Nurse.
• Ability to identify inappropriate bed utilization and refer to Utilization Management physician advisor.

Pay

Compensation range: $58.54 – $91.82 per hour.