Position Summary:

The individual in this position will have overall responsibility for the Case Management Departments across all HSA hospitals. This position will oversee utilization performance improvement and operational management of the Case Management Departments in order to promote effective utilization of hospital resources, ensure processes, support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services. This position will be responsible to ensure Case Management standardization of processes and goals are established and met by the departments on a consistent basis.

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 Hospital policy
• Education provided to physicians, patients, families and caregivers

The individual's responsibilities include the following activities across HSA hospitals: a) oversee department operations to assure effective throughput and reimbursement for services provided, b) lead the implementation and oversight of hospital Utilization Management Plans using data to drive hospital utilization performance improvement, c) ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and HSA 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: (Training, Education, Experience, Skills and Abilities)

Required qualifications include an active Registered Nurse license with at least 5 years acute hospital case management, leadership experience preferred. 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 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 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.

Primary Information, Tools and Systems Used:
• Patient data - hospital admission, discharge, transfer system
• Healthcare staff documentation related to patient care
• Regulatory and payor requirements
• Allscripts Care Management System
• McKesson Care Enhance Review Manager (CERMe) InterQual system
• Crimson
• Clinical data interface and secure faxing
• Patient Medical Record including Cerner and HPF
• Hospital Specific Clinical Software
• Enterprise Reporting: Decision Support reports, PMI reports
• Care Discovery
• Position Control

Communication Skills:

Ability to effectively communicate in writing and orally with all levels of the organization