Description Duties and Responsibilities Oversight of the Facility's Case Management team to ensure compliance with standards of practice and other regulatory requirements related to care management and utilization review. Develop and foster effective collaboration between Case Management Departments, Medical Staff, corporate and facility leaders to ensure an integrated approach to providing care while fulfilling the hospital's goals and objectives. Display an ability to work effectively within the health system's decision making and organizational structures. Work closely with providers as well as internal and external physician advisors for utilization review and management activities Coordinate all UM Committee activities to ensure compliance with meeting frequency and documentation of activity and outcomes Work collaboratively with Revenue Cycle teams and participates in task force meetings related to medical necessity audits and denials. Participate in appeals processes and work collaboratively with vendors to ensure the effectiveness and timeliness of appeals Analyze length of stay and readmissions data and incorporate measures with Operations team members, Corporate Case Management Directors and other facility leaders to ensure goals are met Introduce evidenced based practices geared to improve case management and transitions Conduct regular staff meetings to review pertinent Federal and State regulatory requirements, emerging internal and external trends, and provide general training for staff Qualifications II. Position Requirements: A. Licensure/Certification/Registration: Applicants with the following licensure may be considered : Oklahoma RN B. Education: BSN preferred, Registered nurse is required. Certification in Case Management or Utiliz ation Review is preferred Skills Demonstrated leadership and complex organizational management skills
Excellent management, problem solving, team building & organizational skills
Familiarity with Federal & State regulations related to case management discharge planning.
Knowledge of integrated discharge planning practices and resources available to patients
Demonstrated knowledge of RACs, MACs and the Medicare appeals process
Ability to work with Administration, Physicians, and staff in multiple settings
Ability to compile reports and interpret data
Ability to prepare and administer presentations
Ability to interpret and apply InterQual criteria
Experience: A minimum of 5 years experience in case management, discharge planning, and/or utilization review in an inpatient acute care setting. Strong clinical background is preferred.
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