Director Case Management

RN Director of Case Management

Contra Costa Valley, California

The RN Director of Case Management in Northern California is a subject matter expert in all aspects of case management, providing direct onsite support, ensuring best practices, and change management.

This role evaluates the efficiency, appropriateness, necessity of the use of medical services, procedures, and level of care for patients.

Uses data analysis and develops and implements strategies to improve workflows and processes / procedures to enhance utilization review and discharge planning.

Works to ensure care is delivered to patients in appropriate time frames to maximize patient flow and reimbursement.

Qualifications :

• Bachelor degree in Nursing required
• Master’s degree in Nursing, Business Administration or Hospital Administration preferred
• Registered Nurse required
• Director of Case Management in an Acute Hospital required
• Accredited Case Manager (ACM) preferred

Responsibilities :

• Analytical ability to serve in an advisory / consultative role in determining and / or developing strategies, policies, processes, protocols and method
• Evaluates and directs complex systems that foster innovative approaches to procedures / processes
• Fiscal skills to monitor and control costs and revenue
• Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously
• Strong communication and interpersonal skills for a variety of communication modalities is required to include leading meetings, making formal presentations, and writing complex documents and managing complex relationships
• Teaching abilities to conduct educational programs
• Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful manner
• Leadership skills including technical knowledge of community resources, regulatory requirements, reimbursements and Utilization Management procedures
• Implements and supports with business case staffing requests utilizing the Case Management staffing recommendations and hospital budgetary guidelines
• Holds regular departmental meetings with staff to provide updates and provides for ongoing education
• Completes initial and annual competency and evaluation review on all Case Management staff
• Follows the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
• Develops action plan for case managers that fail to meet the IRR acceptable match rate to ensure improvement in the accurate application of InterQual criteria
• Implements and monitors processes to ensure medical necessity review processes are in place for patients to be in the appropriate status and level of care
• Oversees submission of cases to Physician Advisor review to ensure timely referral, follow up and documentation
• Implements and monitors Utilization Review process in place to communicate appropriate clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
• Advocates for the patient and hospital with payers to secure appropriate payment for services Implements and monitors physician peer to peer review process with payers to resolve denials or downgrades concurrently
• Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Ensures Case Management staff use electronic referral request process for patient placements
• Monitors to ensure that patient choice is documented per CMS regulations
• Works with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
• Participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
• Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient choice and available resources
• Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
• Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
• Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
• Provides education to physicians regarding medical necessity, complete and accurate documentation, and compliance with related regulatory requirements
• Prepares and provides data to physicians and the hospital on utilization of resources
• Provides education to Case Management staff, physicians and the healthcare team
• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting Case Management scope of services
• Ensures that the department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation
• Operates within the RN scope of practice as defined by state licensing regulations

To apply for Case Management opportunities or to inquire further, interested individuals can directly contact Michelle Boeckmann directly at Michelle@HCRecruiter.

com or visit our Case Management website at

Feel free to share these contact details with anyone who might be interested in Case Management and Utilization opportunities.

Michelle Boeckmann President Case Management Recruitment

Direct : 615-465-0292

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