Director of Case Management

Confidential; New Jersey; On-site; USD 110,000 - 160,000; Full time

Job summary

Confidential is seeking a senior leader to mentor Social Workers and Case Managers within the Case Management Department. The role focuses on utilization review, discharge planning, and maintaining regulatory compliance across CMS guidelines.

The successful candidate will act as a clinical expert, conduct second-level determinations, collaborate with medical staff, and drive process improvements to ensure high-quality patient care and timely dispositions.

Qualifications

• Knowledge of Utilization Review criteria and discharge planning and length of stay initiatives.
• Knowledge in Medicaid, Medicare, Managed Care review and documentation requirements; familiarity with state and federal regulations, DNV standards for acute care facilities.

Responsibilities

• Mentor and oversee Social Workers and Case Managers; assist daily operations of Case Management Department.
• Conduct 2nd level status determinations and medical necessity reviews as requested by case managers.
• Educate physicians on appropriateness of level of care and timely discharge planning.
• Coordinate with medical staff to resolve utilization management issues and ensure optimal patient outcomes.
• Comply with CMS Hospital conditions of participation for Utilization Review and applicable regulatory requirements.
• Develop processes with administration to improve quality of care and electronic documentation.

Skills

Utilization review knowledge

Discharge planning

Regulatory compliance

Education

Nursing or Medical degree

NJ license

Job description

• Mentors and oversees the work of Social Workers and Case Managers. Acts as Administrator, assisting with daily operation of Case Management Department.
• Supports case managers via review of case information to assist with the best plan of action for the patient and reviews difficult cases where necessary.
• Acts as a clinical expert, consultant for utilization review staff liaison with medical staff on issues related to accurate documentation, utilization, regulatory compliance, length of stay and appropriate alternatives to acute care.
• Conducts 2nd level status determinations and medical necessity reviews as requested by case managers meeting required timeframes.
• Attends rounds or length of stay meetings regularly to provide education and insight for effective management of cases.
• Directs interaction/communication with the medical staff to resolve issues that affect utilization management or quality and collaborates with member of interdisciplinary team to ensure optimal patient outcome.
• Active member of the hospital's Utilization Review Committee and functions in accordance with the CMS Hospital conditions of participation for Utilization Review and other applicable regulatory/compliance and accrediting requirements.
• Complies with both CMS and payer required decision making timeframes; responds to requests for assistance/intervention within agreed to timeframes.
• Work with administration and clinical committees to develop processes and guidelines to improve quality care and provides clinical support with issues regarding electronic documentation.
• Ensures Social Workers are completing a EARC-PAS screen and faxes to appropriate agency.
• Participates in coaching and educating physicians on the appropriateness of level of care and timely need for discharge planning.
• Creatively negotiates, coordinates, and advocates community based services (DYFS, APS, Office of Public Guardian, DDD, etc.) to assure continuation of care and special services appropriate to the age of patients and needs identified.
• Performs other job duties and responsibilities as assigned.
• Develops and maintains relationships with community partners.

Qualifications and Skills

• Knowledge of Utilization Review criteria and discharge planning and length of stay initiatives.
• Knowledge in Medicaid, Medicare, Managed Care review and documentation requirements. Is knowledgeable of state and federal regulations, DNV standards and practices for acute care facilities.

Education, Experience and Certification/Licensure Requirements

• Nursing and/or Medical degree from an accredited school, licensed in the state of NJ.
• At least 2 years direct patient care in an acute care setting.