Case Management Director

May 15, 2021
Jul 11, 2021
Full Time
The Director of Case Management is responsible for leading the clinical and financial processes for Case Management that impact authorization for
inpatient and outpatient services; net collections for hospital based services; and pay for performance projects in both inpatient and ambulatory
settings. Actively works in all phases of the revenue cycle to identify opportunities for process improvements and net revenue optimization.
Strategically leads appropriate departments and executive leaders to resolve organizational reimbursement issues related to patient throughput and
payer authorizations; analyze key clinical and financial data metrics; systematically review findings with key stakeholders; and make recommendations
to improve both clinical and revenue cycle outcomes.
The Director provides enterprise wide oversight for case management and car coordination services by overseeing the delivery of services from
ambulatory clinics to intensive care units; financially securing authorizations for payments through pre-service, concurrent and retrospective clinical
review processes with federal programs and commercial payers; avoiding bad debt related to unauthorized hospital days, un-sponsored care or high
risk situations; optimizing pay for performance through readmission prevention, ED Case Management and ambulatory care coordination services; and
enhancing patient / family and physician / provider satisfaction with care management across the enterprise. The Director leads clinical teams,
physicians, and executive leaders to identify capacity issues that create barriers to patient flow . The Director represents the organization with external
entities such as third party payers, regulatory agencies, other health care institutions, vendors, patients and families. The Director of Case
Management will assure hospital compliance in access related functions are in line with CMS and JACHO guidelines, including but not limited to
financial assistance policy , medical necessity , observation status, Medicare Important Notice, patient/family choice in post-acute care services and
other regulatory guidelines. The Director of Case Management leads the organization in a manner that is patient-centered and respectful of all other
customers and stakeholders. This position will work in collaboration with the Director of Patient Financial services, Director of Physician Financial
Services, Director of Patient Access and the Director of Revenue Integrity , Chief Information Officer , and administrative as well as clinical leaders in
ambulatory care departments.


Minimum Education

Specific Requirements and Preferences
Nursing degree (Required)
CCM (Preferred)

Minimum Work Experience
7 years of Case Management related experience including discharge planning, utilization review, clinical auditing, and
financial/clinical data reporting (Required)
6 years of supervisory experience required with executive level leadership experience (Preferred) .

Required Skills/Knowledge
Demonstrated success in managing day-to-day operations of a large scale, high volume case management and care coordination functions for an academic medical center and/or large, complex, corporate hospital/health system that includes inpatient, emergency, ancillary and ambulatory service lines.
Proven track record of meeting department goals without an adverse impact on employee morale or customer satisfaction.
Ability to plan, implement, and effect transition from a "transaction" orientation to a high quality customer service orientation which includes the physicians and patients as customers.
In depth knowledge of general business concepts including financial management and accounting principles and practice.
Ability to analyze and present complex financial, productivity and outcome data using software and data warehouse tools.
Working experience with medical management criteria such as Milliman and/or InterQual.
Excellent written and verbal communication and presentation skills.
Experience with Cerner systems preferred.

Functional Accountabilities

Resource Management
1. Oversee human resource activities of assigned managers and team members including selection and termination; training and
2. staff/leadership development; staff scheduling for 7 day a week coverage of all essential departmental functions, performance evaluation and remediation.
3. Develop and enhance both staff performance and objective performance outcomes for all Access staff whether they are assigned to
4. Revenue Cycle or other departments (i.e. clinic based staff, surgery schedulers, etc).
5. Update staff with relevant information from Hospital and CNMA via written communication and staff meetings.
6. Represent staff and revenue cycle interests in organizational committees and leadership meetings.
7. Collaboratively define staff work flows, work load, priorities and resource allocation across enterprise.

Revenue Cycle Management
1. Assess all phases of the revenue cycle to identify opportunities for improvement; work with appropriate departments to resolve high risk issues; report findings and make recommendations to Vice President of Revenue Cycle and Care Management.
2. Systematically measure vendor performance and meet with them regularly and ensure vendors have appropriate processes in place to maximize net revenue.
3. Lead projects related to payer performance and work with Managed Care and others to address payer specific issues.
4. Identify potential billing compliance issues; assess enterprise risk; research resolutions; and work closely with Compliance
5. Department to prioritize and correct potential issues.
6. Work with Federal, State, and local authorities to review regulatory issues that affect submission and adjudication of claims.
7. Reinforce organizational financial decision making processes with operational and financial data and information.

Clinical Resource Management
1. Actively manage and report medical necessity denials to identify trends and specific issues that need actions plans for resolution at the aggregate or individual level.
2. Manage systems that impact patient throughput, length of stay, utilization management, ambulatory care management and pay for
3. performance.
4. Lead recoveries of medical necessity related appeals utilizing both internal and external resources; and implement process improvement to minimize final denials, avoidable days and variance days.
5. Analyze and escalate denial trends and identify internal and external causes and solutions.
6. Manage Case Management processes across the enterprise to ensure timely care delivery using strategic education, denial audits, and process improvements.
7. Lead the discussion and action plans around high risk and long length of stay patients to attain optimal clinical outcomes while mitigating negative financial impacts.

Management of Information Technology and Resources
1. Identify opportunities in the use of existing and new administrative and clinical information technology and decision-support tools to improve revenue cycle performance efficiency and productivity .
2. Oversee review, update and implementation of access and revenue cycle related policies and procedures.
3. Responsible for leading system conversions, upgrades, and applications to ensure cross functional operational requirements of Revenue Cycle are met.

Education and Training
1. Lead physicians, clinical teams and executives in the development of educational programs to minimize denials and financial losses due to prolonged hospital stays, uncovered services, lacking clinical documentation and missed pay for performance opportunities.
2. Provide hospital wide education on Clinical Resource Management program and initiatives across all clinical areas within the organization to ensure optimal clinical and financial outcomes.
3. Implement the system for initial and ongoing staff development that includes competencies and continuing education programs.
4. Co-manage the Shared Leadership Education Committee with the educational activities for Case Managers on organizational initiatives and professional trends in practice.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification

Performance Improvement/Problem-solving
Cost Management/Financial Responsibility

Childrens National Hospital is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law.

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