RN Manager - Case Management, Full-Time (Onsite)

General Summary of Duties

We are seeking an experienced and dynamic Registered Nurse (RN) to lead our Case Management team, with a strong focus on Utilization Review. The Manager of Case Management will oversee the daily operations of the case management department, ensuring efficient utilization management, compliance with regulatory requirements, and optimal patient care outcomes. This role requires a strategic thinker who can collaborate across departments and with medical staff to improve care coordination and reduce unnecessary hospital stays.

Requirements

• RN license required with BSN Certification in Case Management (CCM) or Utilization Review (ACM) strongly preferred
• Familiarity with EPIC and MCG Indicia preferred
• Minimum of 3 years of previous case management experience is required in a hospital setting
• Understands the importance of teamwork when achieving desired results
• Understands basic CMS guidelines and has experience working with payor specific medical policies and reimbursement methodologies
• Understands how to use InterQual or Milliman to determine the appropriate level of care
• Understands basic coding principles and chargemaster operations
• Able to be assertive with persuasive communication skills; action oriented
• Able to be organized and efficient with time
• Able to be compassionate to people and their situations to work with them in a positive way that will help them make positive forward strides
• Critical thinking skills, decisive judgment, and the ability to work with minimal supervision while meeting firm deadlines
• Communication skills necessary to be a good listener and speak in an understandable way
• Previous supervisory experience preferred

Essential Functions

• Leadership and Team Management:
• Lead, mentor, and manage the small case management team
• Develop, maintain, and implement policies and procedures to improve departmental efficiency and compliance with regulatory agencies
• Conduct regular performance evaluations and provide professional development opportunities
• Utilization Review and Compliance:
• Oversee the utilization review process to ensure appropriate use of healthcare services
• Ensure compliance with Medicare and commercial payer requirements
• Analyze data to identify trends in utilization and recommend process improvements
• Care Coordination and Case Management:
• Facilitate seamless transitions of care across the continuum (e.g., inpatient, outpatient, home health)
• Collaborate with physicians, nurses, and other healthcare professionals to develop and implement patient-centered care
• Facilitate the discharge planning process for our patient population
• Data Analysis and Reporting:
• Monitor and report on key performance indicators (KPIs), including readmission rates, length of stay (LOS), and denial management
• Monitor and maintain regulatory forms (e.g., IMM, MOON)
• Regulatory Compliance and Accreditation:
• Ensure department adherence to DNV standards, CMS Condition of Participation, and other accrediting bodies
• Stay updated on changes in healthcare regulations and payer policies
• Interdisciplinary Collaboration:
• Serve as a liaison between case management, clinical staff, and administrative leadership
• Participate in hospital committees and quality improvement initiatives

Physical Demands

• Frequent sitting, conversing, and listening
• Using hands to touch, handle, or feel objects, tools or controls
• Reaching with hands and arms
• Occasional lifting and carrying up to 15 pounds
• Pushing and pulling up to 5 pounds
• Standing and walking for at least five hours per day

Work Environment

• Sit, converse, and listen
• Use hands to touch, handle, or feel objects, tools or controls
• Reach with hands and arms
• Occasionally lift and carry up to 15 pounds
• Push and pull up to 5 pounds
• Stand and walk for at least five hours per day