Job Description:

The Manager for Case Management provides oversight, guidance and leadership to Case Management staff and patient status/utilization review functions. Provides direct oversight and accountability for real-time patient status determination at point of entry (emergency department, direct admissions, and transfers), ensuring compliance with CMS regulations, the two-midnight rule, and evidence-based criteria (InterQual/MCG) to optimize reimbursement, minimize denials, and ensure an appropriate level of care. Develops services, policies, procedures, resource plans, to support case management, bed management, discharge planning, level-of-care determination, authorization, denial prevention, and payer communication. Collects and analyzes data to implement departmental and interdepartmental performance improvement initiatives that improve resource utilization, reimbursement accuracy, regulatory compliance, and organizational efficiency. Oversees staff responsible for care coordination, medical necessity review, documentation, and communication with patients, families, providers, payers, and the interdisciplinary healthcare team.

Minimum Job Requirements

Work Experience:

Five years of direct patient care experience in a healthcare setting required.

Three years of experience in Case Management required.

Three years of management experience required.

License/Registration/Certification:

Licensed to practice as a Registered Nurse in the state of Texas.

Certification as a Case Manager (CCM) or Accredited Case Manager (ACM) preferred.

Education and Training:

Bachelor's degree in Nursing required. Master's degree in Nursing preferred.

Skills:

1. Knowledge of case management principles and standard practices.
2. Demonstrated effective oral and written communication skills.
3. Strong analytical and data management skills
4. Knowledgeable of community resources.
5. Develops effective working relationships with physicians and interdisciplinary team.
6. Works well with people of all social, economic, and cultural backgrounds.
7. Flexible, open-minded and adaptable to change.
8. Excellent interpersonal, communication and negotiation skills with ability to convey understanding progress of complex issues.
9. Leadership and training skills.
10. Strong organizational and time management skills.
11. Working knowledge/experience in managed care and payor issues.
12. Bilingual English/Spanish preferred, culturally sensitive.