Director, Case Management

RiseMe; New York (NY); On-site; USD 120,000 - 180,000; Full time

Job summary

RiseMe seeks a seasoned Director of Case Management to lead the administration, direction and evaluation of Case Management services in a hospital setting. You will drive utilization review, care coordination and transition management while aligning with strategic goals and regulatory requirements.

Ideal candidates will have RN licensure in New York, 5–10 years of acute care experience, and leadership in case management with CMS knowledge.

Qualifications

• Bachelor’s Degree in Nursing required; advanced degree preferred
• New York State Licensed Registered Nurse
• Certification in Case Management and PRI/Screen strongly preferred
• Minimum 5–10 years acute care clinical experience
• Minimum 5 years case management leadership experience
• Strong knowledge of CMS Conditions of Participation related to utilization management

Responsibilities

• Direct case management and social work activities to monitor quality of care
• Address and resolve patient/family and staff satisfaction issues
• Identify and intervene on LOS issues
• Develop and evaluate case management for high risk/high volume patients
• Implement and evaluate concurrent utilization review practices
• Effectively manage concurrent denials
• Utilize data to improve department activities and performance
• Collaborate with other department leaders to integrate Case Management across the continuum
• Monitor regulatory readiness (JCAHO, federal and state)
• Identify and manage clinical revenue enhancement projects
• Assist with staff learning experiences and training
• Maintain and update policies for case management
• Communicate policy changes to staff
• Ensure PHI handling complies with HIPAA

Skills

Leadership

CMS Knowledge

HIPAA Compliance

Problem Solving

Communication

Supervision

Strategic Planning

Education

Bachelor’s Degree in Nursing

Master’s Degree in Nursing or related field

New York State RN license

Tools

MS Word

Excel

Case management/denials software

CMS Compliance Software

Job description

Job Purpose

The Director, Case Management is responsible for the administration, direction and evaluation of Case Management services. Develops strategies for the advancement of case management, to include utilization management, coordination of care and transition management. Responsible for projects consistent with the mission, vision, strategic plan, regulatory agencies and clinical needs of the Hospital and Clinical Staff. Critical responsibilities include achievement of annual and periodic goals for significant indicators of performance. The Director, Case Management is responsible to demonstrate, through action and plans, that there is consistent standard of excellence to which all department work is expected to conform.

Duties & Responsibilities

• Direct case management and social work activities to monitor quality of care, verify appropriate documentation and compliance with standards
• Address and resolve patient/family and staff satisfaction issues on an ongoing basis
• Identify and intervene about specific LOS (length of stay) issues on an ongoing basis
• Develop and evaluate case management for high risk/high volume patients
• Implement and evaluate concurrent utilization review practices
• Effectively manages concurrent denials
• Utilize data to improve department activities and performance
• Collaborate with other department leaders to assure the smooth integration ofCase Management/Social Work services across the continuum
• Monitor and maintain JCAHO, federal and state regulatory readiness
• Identify and manage clinical revenue enhancement projects
• Assist with programs providing learning experiences for staff and affiliating students
• Actively participate in the formulation and revision of administrative and departmental case management policies and procedures
• Communicate and interpret policy additions/ revisions to staff
• Other duties as assigned

• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• Bachelor’s Degree in Nursing required; Master’s Degree in Nursing and other health care related courses preferred
• Minimum of five (5) to ten (10) years acute care clinical experience
• Minimum of five (5) years case management leadership experience
• New York State Licensed Registered Professional Nurse
• Certification in Hospital Management Strongly Preferred
• Certification in Patient Review Instrument (PRI) and Screen
• Certification in Case Management
• Broad knowledge of medical, nursing, and allied health sciences, community resources case management regulatory requirements, and the revenue cycle
• PC experience word processing, spreadsheets, and case management/denials software structures
• Strong understanding of CMS Conditions of Participation as it relates to utilization management, coordination of care and transition management
• Knowledge of HIPAA, privacy, healthcare laws, regulations and standards
• Advanced Knowledge in MS Word and Excel
• Demonstrated leadership ability required
• Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form
• Ability to deal with problems involving several concrete variables in standardized situations
• Strong managerial, leadership, and interpersonal skills
• Requires an ability to initiate action, creatively solve problems, meet goals, and produce results through effective supervision of employees

• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented

Working Conditions

• Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
• Physical Demands:While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Perform light lifting (up to 15 pounds).
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
• Work Environment:Works in a well-lighted/ventilated office setting. Subject to frequent interruptions. Minimal occupational exposure to infectious diseases, blood borne pathogens, hazardous chemicals, noxious odors, latex, or musculoskeletal injuries. Operate Office machines properly and in accordance with Hospital safety standards. Ability to work in accordance with Hospital Safety Standards.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.