RN Manager - Case Management, Full-Time (Onsite)

Job DetailsDescriptionGENERAL SUMMARY OF DUTIES: We are seeking an experienced and dynamic Registered Nurse (RN) to lead our Case Management team, with a strong focus on Utilization Review. The Manager of Case Management will oversee the daily operations of the case management department, ensuring efficient utilization management, compliance with regulatory requirements, and optimal patient care outcomes. This role requires a strategic thinker who can collaborate across departments and with medical staff to improve care coordination and reduce unnecessary hospital stays.RequirementsRN license required with BSN Certification in Case Management (CCM) or Utilization Review (ACM) strongly preferredFamiliarity with EPIC and MCG Indicia preferred Minimum of 3 years of previous case management experience is required in a hospital settingUnderstands the importance of teamwork when achieving desired resultsUnderstands basic CMS guidelines and has experience working with payor specific medical policies and reimbursement methodologiesUnderstands how to use InterQual or Milliman to determine the appropriate level of careUnderstands basic coding principles and chargemaster operationsAbility to be assertive with persuasive communication skills; action orientedAbility to be organized and efficient with timeAbility to be compassionate to people and their situations to work with them in a positive way that will help them make positive forward stridesCritical thinking skills, decisive judgment, and the ability to work with minimal supervision while meeting firm deadlinesCommunication skills necessary to be a good listener and speak in an understandable wayPrevious supervisory experience preferredEssential FunctionsLeadership and Team ManagementLead, mentor, and manage the small case management teamDevelop, maintain, and implement policies and procedures to improve departmental efficiency and compliance with regulatory agenciesConduct regular performance evaluations and provide professional development opportunitiesUtilization Review and ComplianceOversee the utilization review process to ensure appropriate use of healthcare servicesEnsure compliance with Medicare and commercial payer requirementsAnalyze data to identify trends in utilization and recommend process improvementsCare Coordination and Case ManagementFacilitate seamless transitions of care across the continuum (e.g., inpatient, outpatient, home health)Collaborate with physicians, nurses, and other healthcare professionals to develop and implement patient-centered careFacilitate the discharge planning process for our patient populationData Analysis and ReportingMonitor and report on key performance indicators (KPIs), including readmission rates, length of stay (LOS), and denial managementMonitor and maintain regulatory forms (e.g., IMM, MOON)Regulatory Compliance and AccreditationEnsure department adherence to DNV standards, CMS Condition of Participation, and other accrediting bodiesStay updated on changes in healthcare regulations and payer policiesInterdisciplinary CollaborationServe as a liaison between case management, clinical staff, and administrative leadershipParticipate in hospital committees and quality improvement initiativesPhysical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.The employee must be able to lift and/or carry 15 pounds on an occasional basis and be able to push/pull 5 pounds on an occasional basis.The employee must be able to stand and/or walk at least five hours per dayWork EnvironmentThe work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.