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Job Description
Responsible for hospital utilization performance improvement and operational management of the Case Management Department 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 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 company policy; Education provided to physicians, patient, families and caregivers. Completes established competencies for the position within designated introductory period. Other related duties as assigned.

IF REGISTERED NURSE:

MINIMUM EDUCATION: Bachelor’s Degree from an accredited school, college or university as a Registered Nurse 

PREFERRED EDUCATION: Master’s Degree from an accredited college or university in Nursing or related field 

MINIMUM EXPERIENCE: 2 years in acute hospital case management, healthcare or leadership experiences 

PREFERRED EXPERIENCE: 5 years in acute hospital case management. McKesson InterQual® experience and Business Planning experience 

REQUIRED CERTIFICATIONS/LICENSURE: Possession of current Texas State registration as a Registered Nurse 

PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM

IF SOCIAL WORKER:

MINIMUM EDUCATION: Master’s Degree from an accredited school, college or university as a Social Worker 

MINIMUM EXPERIENCE: 2 years in acute hospital case management, leadership experience

REQUIRED CERTIFICATIONS/LICENSURE: Possession of current Texas State registration as a Social Worker Licensed Certified Social Worker (LCSW) or Licensed Master Social Worker (LMSW)

PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM)

Responsibilities
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 and revenue cycle processes are completed accurately and in compliance with CMS regulations and company 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) participate in management of post-acute provider network,
h) ensure compliance with state and federal regulations and TJC accreditation standards and
i) other duties as assigned.

Qualifications
Education:
Required: Bachelor’s degree in business, Nursing or Health Care Administration for RN or master’s in social work for MSW
Preferred: MSN, MBA, MSW, or MHA

Experience:
Required: 3 years of acute hospital case management or healthcare leadership experience
Preferred: 5 years of acute hospital case management leadership multi-site experience

Certifications:
Required: Registered Nurse or LCSW/LMSW license. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN or LCSW/LMSW license for state(s) covered.
Preferred: Accredited Case Manager (ACM)

Physical Demands:
Lift/position up to 25 lbs. Push/pull up to 25 lbs. of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position.
Security Clearance Required: No
Visa Candidate Considered: No
COMPENSATION
Base Salary – USD $100,000 to $130,000
*** Never repost ***
Full-time
Benefits – Full
Relocation Assistance Available – Possible for ideal candidate
Commission Compensation – No
Bonus Eligible – No
Overtime Eligible – No
Interview Travel Reimbursed – No
CANDIDATE DETAILS
Seniority Level – Director
Management Experience Required – No
Minimum Education – Bachelor’s Degree
Willingness to Travel – Occasionally

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