POSITION SUMMARYJOB TITLE:Manager Case Management and Utilization Review
FLSA:Exempt
Non-Exempt
DEPARTMENT:Case Management
GRADE:12
Position SummaryThe Manager of Case Management and Utilization Review is a working manager responsible for the leadership, daily operations, and performance of utilization management, case management, discharge planning, and related social service functions. The manager promotes safe transitions of care, appropriate level-of-care decisions, effective use of resources, regulatory compliance, accurate reimbursement, and timely access to post-acute services.
The manager assumes accountability for departmental planning, staffing, staff development, performance improvement, data analysis, and collaboration with patients, families, providers, payers, and community partners. The manager also performs operational case management and utilization review work as needed to support patient care and department needs.
Essential Functions- Provides leadership and day-to-day management of utilization review, case management, discharge planning, and related social service functions.
- Plans, develops, implements, evaluates, and improves departmental programs, workflows, policies, and procedures in alignment with organizational priorities and applicable requirements.
- Ensures timely assessment of patient needs and coordination of safe, appropriate discharge plans, including post-acute care, home health, durable medical equipment, community resources, and transfers to acute, skilled, residential, or other care settings.
- Supports patient- and family-centered care by addressing barriers to treatment and discharge and facilitating communication among patients, families, providers, nursing, ancillary departments, payers, and community partners.
- Oversees utilization review processes, including level-of-care determinations, medical necessity review, payer communication, authorization activities, and escalation of clinical or reimbursement concerns.
- Promotes appropriate reimbursement for medical services through accurate, timely utilization management and documentation processes.
- Maintains working knowledge of Medicare, Medicaid, managed care, Critical Access Hospital requirements, and other applicable payer and regulatory standards.
- Collects, aggregates, analyzes, and reports clinical and operational data used to evaluate resource utilization, patient flow, department performance, reimbursement, and improvement opportunities.
- Leads the Medical Record and Utilization Review Committee or successor committee, prepares the agenda, and presents case management and utilization review reports.
- Facilitates bed management and monitors inpatient census in relation to Critical Access Hospital requirements; communicates and coordinates actions during high-census or capacity-constrained conditions.
- Participates in quality, accreditation, compliance, denial prevention, and clinical improvement activities and implements corrective actions within the department when indicated.
- Participates in event review and follow-up, including staff education and process improvement arising from identified safety or quality concerns.
- Develops staffing plans and schedules that support safe and effective department operations; adjusts coverage as needed and performs department functions when operationally necessary.
- Recruits, selects, orients, coaches, evaluates, and retains qualified personnel; completes timely performance evaluations and supports individual professional development plans.
- Assesses staff education needs and provides or coordinates education related to case management, utilization review, discharge planning, regulatory requirements, and department workflows.
- Develops, monitors, and manages operational and capital budgets and uses resources responsibly.
- Serves as a clinical and operational resource to staff, providers, patients, and families and supports resolution of complex cases and conflicts.
- Participates in organizational policy development, committees, strategic initiatives, and decision-making activities relevant to the role.
- Participates in the Manager of the Day rotation and participates in Nurse Manager on call rotation.
- Maintains confidentiality of patient, employee, and organizational information and comply with privacy and information-security requirements.
- Maintains professional competence, identifies personal learning needs, and completes education necessary for the role.
- Performs other duties within the registered nurse scope of practice and the manager's competence in support of departmental and organizational needs.
Minimum Qualifications- Graduate of an accredited registered nursing program.
- Current, unrestricted Registered Nurse license in New Hampshire or a current multistate compact license with privilege to practice in New Hampshire.
- Minimum of two years of experience in case management, utilization review or utilization management, discharge planning, quality management, or a closely related acute-care function.
- Demonstrated knowledge of acute-care discharge planning, levels of care, medical necessity, intensity-of-service criteria, and care transitions.
- Working knowledge of Medicare, Medicaid, managed care, and payer authorization and reimbursement processes.
- Demonstrated leadership, communication, problem-solving, conflict-resolution, data-analysis, and organizational skills.
- Proficiency with electronic health records and standard office software, including word processing and spreadsheets.
Preferred Qualifications- Bachelor of Science in Nursing or bachelor's degree in a related healthcare field. A degree in healthcare management or a related field does not replace the Registered Nurse licensure requirement.
- Prior management or supervisory experience in an acute-care setting.
- Experience in a Critical Access Hospital, rural healthcare environment, or home health setting.
- Accredited case management or utilization management certification, such as ACM, CCM, or an equivalent credential. If not held at here, completion within 18 months of employment is expected.
- Knowledge of ICD-10-CM, CPT, and documentation requirements affecting medical necessity and reimbursement.
Professional Expectations- Supports and contributes to the mission, vision, values, and strategic priorities of Littleton Regional Healthcare.
- Maintains professional relationships with patients, families, visitors, staff, providers, payers, and community partners.
- Demonstrates accountability for patient safety, service, regulatory compliance, and responsible stewardship of resources.
