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

About the role

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.

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
• Ability to be assertive with persuasive communication skills; action oriented
• Ability to be organized and efficient with time
• Ability 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

The Manager of Case Management will be responsible for the following 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, and 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, and analyze data to identify trends in utilization and recommend process improvements
• Care Coordination and Case Management: Facilitate seamless transitions of care across the continuum, collaborate with physicians, nurses, and other healthcare professionals to develop and implement patient-centered care, and 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, and monitor and maintain regulatory forms
• Regulatory Compliance and Accreditation: Ensure department adherence to DNV standards, CMS Condition of Participation, and other accrediting bodies, and stay updated on changes in healthcare regulations and payer policies
• Interdisciplinary Collaboration: Serve as a liaison between case management, clinical staff, and administrative leadership, and participate in hospital committees and quality improvement initiatives

Work Environment and Physical Demands

The work environment characteristics and physical demands of this job are as follows:

• The employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms
• Specific vision abilities required by this job include close vision and the ability to adjust focus
• The employee must be able to lift and/or carry 15 pounds on an occasional basis and be able to push/pull 5 pounds on an occasional basis
• The employee must be able to stand and/or walk at least five hours per day