What will you be doing:The
Manager of Clinical Care Coordination, DME Respiratory is responsible for leading clinical care coordination and utilization management functions for the Durable Medical Equipment (DME) division, with a primary focus on CPAP, non-invasive ventilation (NIV), and invasive ventilator services.
This position requires an active Respiratory Therapist (RT) license and serves as the clinical leader responsible for ensuring respiratory-related services are delivered in accordance with evidence-based clinical guidelines, regulatory requirements, and payer-specific criteria.This role ensures timely, compliant, and medically appropriate authorization decisions in accordance with CMS turnaround time (TAT) requirements for both urgent and standard requests. The Manager provides clinical and operational leadership over referral intake, clinical review, authorization decision-making, and provider coordination to ensure optimal patient outcomes, regulatory compliance, and efficient resource utilization.
- Leadership & Team Management: Provides leadership, direction, and oversight to Clinical Care Coordination and Utilization Management staff supporting DME services. Responsible for recruitment, onboarding, training, performance management, coaching, disciplinary actions, and compensation reviews. Ensures staff consistently meet productivity, quality, compliance, and turnaround time benchmarks.
- DME Clinical Oversight (CPAP, NIV, Invasive Ventilators): Oversees clinical review and authorization workflows for DME respiratory services, including CPAP, BiPAP, non-invasive ventilation, and invasive ventilators. Ensures clinical documentation supports medical necessity, appropriate level of care, and alignment with evidence-based guidelines and payer requirements.
- Utilization Management Oversight & CMS TAT Compliance: Directs utilization management activities to ensure timely UM reviews and determinations in accordance with CMS, state, and contractual turnaround time requirements for urgent and standard requests. Monitors TAT performance, escalates risks, and implements corrective actions to maintain compliance.
- Medical Necessity Review & Decision-Making: Ensures accurate application of medical policies, benefit plans, and clinical criteria when making coverage determinations. Oversees appropriate referral of complex or non-standard cases to the Medical Director in accordance with departmental protocols. Monitors approval, denial, and overturn rates to ensure defensible, compliant decisions.
- Resource Allocation & Operational Efficiency: Allocates staff and resources to meet operational demands while maintaining clinical quality and regulatory compliance. Oversees workload distribution, staffing models, and workflow optimization to support timely service delivery within budgetary constraints.
- Staff Development, Training & Compliance: Leads ongoing training and competency development for UM and care coordination staff, including CMS regulations, medical necessity criteria, documentation standards, and DME-specific requirements. Ensures adherence to policies, procedures, and compliance KPIs through audits, coaching, and continuous education.
- Provider, Vendor & Stakeholder Collaboration: Facilitates effective communication with providers, DME vendors, home health agencies, and payers regarding authorizations, denials, documentation requests, and care coordination needs. Ensures provider inquiries and disputes are resolved within established service level agreements (SLAs).
- Performance Monitoring & Process Improvement: Analyzes productivity, quality, cost, denial, and TAT reports to identify trends and improvement opportunities. Leads performance improvement initiatives to enhance efficiency, reduce avoidable denials, support cost containment, and improve patient outcomes.
- Policy, Regulatory & Accreditation Compliance: Ensures departmental compliance with CMS regulations, accreditation standards (NCQA, URAC, as applicable), internal policies, and contractual requirements. Supports audits, regulatory reviews, and corrective action plans as needed.
- Confidentiality & HIPAA Compliance: Maintains strict adherence to HIPAA and privacy regulations. Ensures staff compliance with confidentiality standards and completion of all required compliance and privacy training.
What will you need to succeed:- Active FL Respiratory Therapist (RT) License
- Bachelor's degree in Nursing (BSN), Respiratory Therapist (RT), Healthcare Administration, or a related field (Master's degree preferred).
- Minimum of 3-5 years of experience in utilization management, case management, or a related healthcare setting.
- At least 2 years of leadership or supervisory experience in a healthcare environment.
- Strong understanding of utilization management, medical necessity criteria, and regulatory compliance (e.g., CMS, NCQA, URAC).
Join our team as we strive for excellence through teamwork, where our patients are #1! 
