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JOB SUMMARY
- Responsible for managing overall Care Management department operations including staffing, budgeting, planning, and regulatory compliance. Directly supervises CM Representatives, Utilization Management RNs, and provides coordination with the Care Managers that are unit based. The Manager CM recommends priorities and provides management for functions of utilization review, including but not limited to medical necessity, authorization, concurrent denials, and post-discharge denials. Works in collaboration with the unit-based Care Managers and their manager to provide critical utilization management during the patient stay including the issuance of hospital-issued denial notices, condition code 44, and QIO requests. He/she helps support the Director to assure consistent practice and outcomes involving appropriate level of care, resource utilization, associated revenue cycle activities, safe patient discharge, care transitions, and readmission prevention. The Manager works collaboratively to build relationships with key internal and external stakeholders; provides education about CM program functions, payer, and regulatory requirements including current trends and potential impact on the department, hospital, or system. Works collaboratively with the Nurse Manager Command Center to ensure the Utilization Plan is met and there are smooth handoffs with medical necessity reviews.
Qualifications
EDUCATION REQUIREMENTS
- 4 year / Bachelor's Degree in Nursing, Healthcare, or related field (Required)
- Master's Degree (Preferred)
- 4 - 5 years Acute care case management (Required)
- 3 - 4 years Supervisory and leadership experience with minimum of 2-3 years at manager level in comparable setting (Required)
- Required Certifications/Licensures: Registered Nurse (RN) with current Georgia license
- Preferred Certifications/Licensures: Certified Case Manager (CCM), Accredited Case Manager
- Have near normal vision - Clarity of vision (both near and far), ability to distinguish colors
- Have good - manual dexterity and eye-hand-foot coordination
- Ability to perform - repetitive tasks/motion
- Standing - Frequently within shift (34-66%)
- Walking - Frequently within shift (34-66%)
- Sitting - Occasionally within shift (1-33%)
- Climbing - Occasionally within shift (1-33%)
- Bending/Stooping - Occasionally within shift (1-33%)
- Twist at waist - Occasionally within shift (1-33%)
- Pushing/Pulling - Occasionally within shift (1-33%)
- Lift/carry up to 20 lbs - Occasionally within shift (1-33%)
- Lift/carry > 20 lbs with assistance - Occasionally within shift (1-33%)
- Reaching above shoulder - Occasionally within shift (1-33%)
