Director of Case Management

You’ll be responsible for case management, utilization review, discharge planning, and social services, as well as annual plans and budgets. Handle the financial resources of the patient and family, by coordinating the delivery of quality service. Manage relationships with the payers, physicians, hospital referral sources, and your case management staff. Help facilitate the discharge-planning process, and serve as an advocate for the patient and family. Work to ensure financial reimbursement of every individual case.

Responsibilities:

• Develop and implement the philosophies, policies, procedures and goals for the Case Management Department.
• Train and develop the Case Management staff and motivate them to accomplish department goals and objectives.
• Develop and oversee the annual Case Management budget.
• Prepare and evaluate monthly, quarterly and annual reports of the Department’s functions.
• Provide information regarding changes in Medicare regulations and documentation issues to physicians and others as needed.
• Maintain Prospective Payment System, monthly case log and other files needed for peer review organization and specific needs of the hospital.
• Analyze physician utilization patterns, comparing to national and individual hospital standards. Communicate findings to Utilization Review and other appropriate individuals.
• Discuss denial of coverage related to Utilization Review with the Director of Quality Management. Assist with on-site monitoring reviews by PRO, Blue Cross, outside review organizations and third-party payers.
• Maintain a working relationship with local, state and federal agencies, recognizing the hospital’s position in the community and its need for cooperation and assistance from such services.

Qualifications - External

The candidate must be an RN or Licensed Social Worker with clinical healthcare experience in a rehabilitation or acute-care setting. Should be knowledgeable in TQM/QI and have recent experience as a Case Manager in insurance, worker’s compensation or medical management.