Job Description

Position Summary

The Manager, Case Management is responsible for strategic direction and operational leadership for all case management activities across Steward’s Northeast Division as well as high level operations, ongoing quality, productivity and consistency of case management processes. Maintains corporate relationships both within and outside of Steward. Other responsibilities include strategic planning, development and implementation of operational plans, education and collaboration with physician leaders, facility leaders and service line leaders including but not limited to CDI, HIM, Audit & Appeal, physicians/clinicians, Revenue Operations.

The Manager, Case Management will have direct oversight of multiple locations. Day-to-day responsibilities will include patient discharge procedures, community service accessibility, and identification of potential barriers to patient treatment. Additional responsibilities include operational oversight, managing department budgets, quality assurance, corporate compliance, and developing department goals. This role will maintain consistent case management and utilization review processes throughout Steward Health Care System.

The hospital Directors of Case Management will have a dotted line to the Manager, Case Management.

Key Responsibilities

  • Monitor the overall utilization of services
  • Determine the appropriateness of admission and care
  • Administer a closely regulated, denial avoidance process
  • Identify denial trends and develop a monitoring system for process improvement opportunities
  • Develop and communicate plan to hospital leadership and directors/managers
  • Participate is a physician advisor program
  • Medical necessity focus/review to ensure inpatient vs outpatient status assignment, documentation to support medical necessity and seamless authorization workflow.
  • Develops integrated case management program:
    • Evaluates current case management services and identifies needs and opportunities for quality improvements and increased consistency across facilities.
    • Develops policies and procedures to support integration and effectiveness of case management efforts.
    • Leads efforts to develop comprehensive large case management program.
    • Works closely with Physician Advisors.
    • Provides guidance to providers regarding utilization review process, results interpretation and identifying needs.
    • Promotes Denials Management coordination between Site Directors, Denials Management Team, HIM, Coding, Clinical Documentation Specialists ,Business Office, and Physician advisor
    • Identifies operational gaps and challenges and develops strategies and interventions to improve performance management
    • Facilitates effective denial management processes by monitoring payer reimbursement from pre admission to post discharge
    • Participates in the evaluation of community resources utilization.
    • Negotiate contracts with facilities and vendors as necessary for patient continuum of care.
    • Standardizes Utilization Review Committee plans, agendas, and committee participants under direction of the CMO.
  • Ensures information systems are in place to support case management:
    • Coordinates evaluation of software packages and makes recommendations.
    • Ensures appropriate interface with Meditech system.
    • Maintain appropriate educational training for computer systems with Case Management Department Directors.
    • Work with liaison in IS department to develop department specific reports for daily workflow and data collection.
  • Coordinates disease management efforts:
    • Ensures that appropriate protocols are being developed to support disease management programs.
    • Develops disease management committees.
    • Participates with CM Directors in interdisciplinary teams to institute system-wide supports for disease management initiatives.
    • Work in collaboration with insurance carriers to promote Disease Management programs to medical staff for appropriate referrals.
  • Provides educational programs regarding managed care programs and CMS:
    • Develops and delivers case management principles to physicians, staff and others.
    • Work with physician leadership to educate physician staff on an ongoing basis about changes to managed care and CMS regulations.
    • Develops Educational programs and ensures quarterly education is provided to Case Management staff.
  • Develops case management organization:
    • Develops case management organization and staffing plan with Case Management Directors.
    • Defines new positions and in hiring Case Management Directors.
    • Oversees the work of case management directors and providers for the ongoing development of performance.
    • Assists with the development and manages case management budget.
    • Develops a database, which quantifies and tracks ongoing case management initiatives resulting from third party payment issues.
    • Work with Case Management Directors and department leaders to increase quality of patient care.
  • Case Management Duties:
    • Act as a resource for all Case Management Directors and staff.
    • Educate nursing staff and ancillary departments about multidisciplinary care rounds.
    • Establish consistent processes across Steward facilities related to LOS huddles, multi -disciplinary rounds, short stay hospitalizations and other relevant processes.
  • Travel to the Steward Health Care System Massachusetts facilities.
  • Performs related and unrelated responsibilities, as needed.

Required Knowledge and Skills

  • Knowledge of TJC requirements
  • Knowledge of quality assurance, standards compliance, and outcome management
  • Knowledge of external medical case management programs
  • Knowledge and application of reimbursement guidelines
  • Knowledge of payment/reimbursement systems
  • Knowledge of patient rights and commitment to patient advocacy
  • Effective educator skills
  • Excellent written and oral communication skills
  • Effective crisis management skills
  • Effective team leadership skills
  • Ability to collect, document, and analyze data
  • Understanding of claims submission process
  • Word processing and data entry skills
  • Network access to community, state, and national resources and health services organizations
  • Application of budgetary skills
  • Ability to effectively manage staff
  • Ability to prioritize and work in concert with the facility CEO and medical staff
  • Ability to assist in training activities
  • Demonstrates effective resource management
  • Demonstrated experience and competency in working with individuals and groups
  • Application of counseling skills in interpersonal behaviors and conflict resolution
  • Knowledge of Clinical Documentation Specialist and Coding roles

Education and Experience

  1. Education: Master's Degree in Nursing, Healthcare, Business or related field required or within 12 months of hire
  2. Experience (Type & Length): Minimum of five years management experience in a hospital related healthcare environment required. Three years of case management/utilization review or related experience required.
  3. Certification/Licensure: Current RN licensure in MA in good standing. Certification in Case Management or Utilization Review preferred
  4. Software/Hardware: Meditech; MS Office

Application Instructions

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