JOB SUMMARY:
Director Case Management develops and supervises policies and programs to ensure the delivery of case management services meets all patient/family psychosocial needs and ensures planning, implementation, and evaluation of care for patients across the health care episode. Supervises patient and organization financial/medical resources to maximize recovery and meet all regulatory requirements. Actively participates in organizational projects and programs by developing and implementing programs designed to increase the optimization of patient recovery and improved outcomes. Acts as a mentor and coach to fully develop the performance of each individual case manager. Provides departmental education designed to enhance knowledge and performance of case management responsibilities. Provides information to increase knowledge of regulations and enhance compliance with regulatory guidelines which govern case management functions.
ESSENTIAL VALUES-BASED, LEADERSHIP AND MANAGEMENT COMPETENCIES:
Demonstrates competencies in line with the five core values that are the foundation of all activities performed by employees in order to achieve the Mission of Artesia General Hospital.
• Servant Leadership: Leading by example to support both patients and colleagues with humility and purpose.
• Excellence: Consistently striving for the highest standards in patient care, image quality, and safety.
• Respect: Valuing the dignity of every patient, family member, and team member through compassionate communication and care.
• Virtuousness: Acting with integrity, honesty, and accountability in all clinical and regulatory responsibilities.
• Innovation: Embracing continuous improvement and utilizing advanced CT technology to enhance diagnostic imaging.
• Community: Participating in outreach and health awareness to improve the well-being of our region.
• Education: Sharing knowledge with patients, staff, and students to foster understanding and better health outcomes.
ESSENTIAL FUNCTIONS:
Oversee the Case Management Department and provide directs supervision to all department personnel. Ensures compliance with all PHI and HIPAA for each patient in accordance with hospital policy and federal regulations. Supervises department to ensure safety in the workplace and a safe patient environment at all times. Demonstrates the ability to give clear and concise instructions as to assignment objectives and methods, and reviews results at all critical points elated to case management and utilization review practices.
ADDITIONAL RESPONSIBILITIES:
• As assigned.
KNOWLEDGE/SKILL/ABILITIES:
• Knowledge of office Medicare, Insurance, and Medicaid guidelines and regulations.
• Knowledge of Medical Terminology.
• Knowledge of the utilization review process, related tools, and regulation requirements.
• Knowledge of transition of patient care through the continuum.
• Create and maintain a professional relationship with community resources and agencies.
• Assures that applicable accreditation standards and governmental regulations for areas of responsibility are continually met.
• Will have experience documenting, obtaining insurance authorizations, submissions, and updates in an EHR and case management navigation systems such as MCG (Milliman) and/or InterQual.
• Evaluate patient care data to ensure compliance with clinical guidelines and organizational standards; monitor progress and adjust treatment plans as needed.
• Collaborate with nurses, physicians, therapists, and social services to ensure seamless care transitions and improve patient outcomes.
• Develop clinical care pathways to enhance cost-effectiveness while maintaining quality; promote cost efficiencies and regulatory compliance.
• Hire, train, evaluate, and mentor case management staff; manage budgets, staffing, and operational planning
AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.
INFORMATION MANAGEMENT: Treats all information and data within the scope of the position with appropriate confidentiality and security.
RISK MANAGEMENT/QUALITY MANAGEMENT/SAFETY: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.
ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.
MINIMUM POSITION QUALIFICATIONS:
Education - Graduate from an accredited school of nursing; BSN preferred
Work Experience 3-5 years of experience in case management, direct patient care in acute care setting.
Training
License/Certification Current license as RN BSN or Masters in Social Work required. Certification in Case Management preferred.
Skills Required
- Graduate from an accredited school of nursing
- BSN
- Current license as RN or Masters in Social Work
- Certification in Case Management
- 3-5 years of experience in case management and direct patient care in an acute care setting
- Experience documenting, obtaining insurance authorizations, submissions, and updates in an EHR and case management navigation systems (MCG Milliman and/or InterQual)
- Knowledge of Medicare, Insurance, and Medicaid guidelines and regulations
- Knowledge of medical terminology
- Knowledge of utilization review process, related tools, and regulatory requirements
- Knowledge of transition of patient care through the continuum and development of clinical care pathways
- Experience hiring, training, evaluating, mentoring staff and managing budgets, staffing and operational planning
- Knowledge of PHI and HIPAA compliance
- Ability to create and maintain professional relationships with community resources and agencies
What We Do
Artesia General Hospital is a nonprofit general medical and surgical facility providing advanced, compassionate healthcare services including primary care, emergency care, surgery, orthopedics, and behavioral health to communities in Artesia, Carlsbad, and Roswell, NM.
