The Case Management Director directs the Case Management and Utilization Management activities in more than one hospital. Oversees the facilitation of care coordination of the patient and family through the management of quality clinical service delivery. Partners with external customers, referral sources and payors to ensure the facilitation and coordination of the discharge planning process and serve as the patient and family advocate. Accountable for the facility’s denial management program. Ensures that case management services comply with the Conditions of Participation. Collaborates closely with the hospital CEO/Administrator, COO, CFO, CCO and District Office.

Essential Functions:

Oversees coordination of patient care to facilitate development, monitoring and refinement of treatment plan.

Assumes responsibility for ongoing effective operations of the Case Management Department.

Ensures regular, complete and timely reporting of case management performance outcomes.

Represents and promotes Hospitals to the provider community and to local educational institutions when appropriate.

Implements and monitors process to assure optimal utilization of resources and reimbursement.

Participates as a management team member in the Utilization Management Committee and serves on other committees as required and requested.

Identifies opportunities to achieve hospital goals based on available comparative data and benchmarks.

Aggregates and analyzes hospital utilization services statistics and recommends corrective action, if required.

Ensures areas of responsibility are operating in compliance with CMS, state and JCAHO regulations and standards and with Hospital policies, including documentation and record requirements. Actively participates in surveys and audits.

Qualifications

Education:

Graduate of an accredited program required: RN or BSN preferred; or Masters of Social Work with licensure as required by state regulations; or Master’s degree in healthcare administration, business administration, or clinical specialty

Licenses/Certification:

Healthcare professional licensure required as Registered Nurse, Licensed Clinical Social Worker (LCSW), or Licensed Social Worker (LSW), as required by state.

Certification in Case Management preferred.

Experience:

Minimum three years’ experience in Hospital Case Management.