Position Summary:

The individual in this position has ovaerall responsibility for hospital untilization performance improvement and operationsl management of the Case Management Department in order to promote effective of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughtput, and ensure compliaqnce will all state and federtal regualtaions 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 the right sequence and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Hialeah Hospital policy
• Education provided to physicians, patients, families and caregivers

The individual's responsibilities include the following activities: a) manage department operations to assure effective throughput and reimbursement for services provided, b) lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and Hialeah Hospital policy, d) ensure timely and effective patient transition and planning to support efficient patient throughput, e) implement and monitor processes to prevent payer disputes, f) develop and provide physician education and feedback on hospital utilization, g) ensure compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.

Position Qualification:

Bachelor's Degree, Master’s Degree strongly preferred. At least two years acute hospital case management leadership experience preferred. BLS Certification Required. MSN preferred. Accredited Case Manager (ACM) preferred. McKesson InterQual® experience preferred. Five years acute hospital case management experience preferred. Required skills include 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 and computer literacy. Business planning experience preferred.

Training Requirement:

Must 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. Must complete and demonstrate competency in using the Hialeah Hospital Case Management documentation system within 30 days of hire. Attendance at hospital orientation is required. Must work with regional Performance Management and Innovation (PMI) Case Management leader to complete PE Director of Case Management orientation within 90 days of hire.