Summary
Job Description:
The Manager for Case Management provides oversight, guidance and leadership to Case Management staff and patient status/utilization review functions. Provides direct oversight and accountability for real-time patient status determination at point of entry (emergency department, direct admissions, and transfers), ensuring compliance with CMS regulations, the two-midnight rule, and evidence-based criteria (InterQual/MCG) to optimize reimbursement, minimize denials, and ensure an appropriate level of care. Develops services, policies, procedures, resource plans, to support case management, bed management, discharge planning, level-of-care determination, authorization, denial prevention, and payer communication. Collects and analyzes data to implement departmental and interdepartmental performance improvement initiatives that improve resource utilization, reimbursement accuracy, regulatory compliance, and organizational efficiency. Oversees staff responsible for care coordination, medical necessity review, documentation, and communication with patients, families, providers, payers, and the interdisciplinary healthcare team.
Minimum Job Requirements
Work Experience:
Five years of direct patient care experience in a healthcare setting required.
Three years of experience in Case Management required.
Three years of management experience required.
License/Registration/Certification:
Licensed to practice as a Registered Nurse in the state of Texas.
Certification as a Case Manager (CCM) or Accredited Case Manager (ACM) preferred.
Education and Training:
Bachelor’s degree in Nursing required. Master’s degree in Nursing preferred.
Skills: