Director of Care Management - Mount Sinai Queens Hospital - Full-time - Days

Mount Sinai Medical Center; New York (NY); On-site; USD 127,000 - 191,000; Full time

Job summary

An established industry player is seeking a Director to lead departmental activities in utilization review and case management. This pivotal role involves overseeing clinical services, enhancing performance through data-driven strategies, and ensuring compliance with contractual guidelines. The ideal candidate will have extensive experience in nursing and case management, with a strong focus on collaboration and stakeholder engagement. Join a dynamic team dedicated to excellence in patient care and fostering an inclusive workplace where your contributions will make a significant impact.

Qualifications

• 5+ years of Case Management experience required.
• Supervisory experience in Case Management or related field preferred.

Responsibilities

• Oversee departmental activities in utilization review and discharge planning.
• Develop relationships with stakeholders to ensure satisfactory outcomes.
• Monitor case management activity and identify areas for performance improvement.

Skills

Utilization Review

Case Management

Interqual Criteria

Milliman Criteria

Clinical Nursing

Supervisory Skills

Education

Bachelor of Science in Nursing

Master’s degree in Nursing or healthcare-related field

Job description

Description

The Director will oversee departmental activities involved in utilization review, appeals management, and discharge planning to facilitate the case management process and maximize reimbursement to the hospital. Must be capable of navigating various managed care contractual issues and possess knowledge of Interqual and Milliman criteria. The position also supervises the Social Work Department responsible for discharge planning.

Responsibilities

1. Review departmental clinical services and operations, monitor case management activity, and identify areas for performance improvement by examining productivity and workload. Direct, coach, mentor, and assess staff in clinical case management service delivery.
2. Ensure departmental goals align with institutional visions by developing scope of services, maintaining effective relationships with physicians, and collaborating with other disciplines. Use data to assess goals and implement corrective actions.
3. Oversee activities of onsite Case Managers.
4. Present regular productivity reports and meet with Case Management staff individually to discuss targets and concerns.
5. Attend Joint Conference meetings with major payers.
6. Develop relationships and seek feedback from internal and external stakeholders regarding department activities to ensure satisfactory outcomes.
7. Promote a collaborative approach, focusing on patient processes to influence other services.
8. Develop and implement Utilization Review (UR) strategies based on internal data and external agency data, advising the Medical Director.
9. Ensure discharge appeals are conducted within contractual, federal, and state guidelines, and review data related to avoidable days, denials, length of stay, and other key metrics with leadership.

Qualifications

Education Requirements

• Bachelor of Science in Nursing
• Master’s degree in Nursing or a healthcare-related field

Experience Requirements

• 5 years of Case Management experience
• 6 years of clinical nursing experience
• Previous supervisory experience in Case Management or related field

Licensing and Certification Requirements

• Registered Nurse license issued by the Department of Health/Office of Professions in New York
• Professional Board Certification in leadership and/or clinical specialty preferred
• Basic Life Support (BLS) issued by AHA
• Advanced Cardiovascular Life Support (ACLS) issued by AHA (required in specific departments)
• Neonatal Resuscitation Program (NRP) for Labor and Delivery, NICU
• Pediatric Advanced Life Support (PALS) issued by AHA (required in specific departments)

Employer Description

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an inclusive environment where everyone can contribute to excellence. We share a dedication to outstanding patient care and encourage participation in creating a fair and supportive workplace. Our leaders promote respect, collaboration, and continuous learning to improve patient care and staff experiences.

Our system includes over 48,000 employees across multiple hospitals, outpatient practices, labs, and educational institutions. We are recognized for excellence in various specialties and are dedicated to advancing health through innovation, research, and education.

Equal Opportunity Employer

Mount Sinai is an equal opportunity employer, committed to non-discrimination and fostering a respectful environment for all individuals regardless of characteristics protected by law.

Compensation

The salary range for this role is $127,044 - $190,565 annually, depending on experience and education. Compensation may include bonuses, incentives, or other benefits.