Job Description

Manager - Case Management & Utilization Review

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Job ID: 000E4P
Winfield, AL
Management - Case Management
Full Time - Variable

Posting Description

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At North Mississippi Health Services, our mission is to "continuously improve the health of the people of our region." We aim to "provide the best patient and family-centered care and health services in America." We believe that fulfilling our mission and vision calls us to embrace the best people who form incredible connections with our patients and families.



We take pride in celebrating everything that makes you unique--your talents, perspectives, and passions. At North Mississippi Health Services, we believe in connecting your passion with a purpose. You know what connected feels like when you are part of our team.



#WhatConnectsYou

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JOB SUMMARY

The Case Management Manager at North Mississippi Health Services is responsible for overseeing various critical aspects of patient care and administrative processes. The manager is responsible for evaluating medical necessity, efficiency of healthcare services, and discharge planning. They coordinate with medical staff, nurses, and ancillary departments to ensure accurate coding, compliance with regulations, and appropriate patient care across the continuum. As a manager of people, this role is responsible for supervising a team and optimizing operations within a designated department or area, ensuring productivity and effective team management.




| JOB FUNCTIONS | | - | Case Management Evaluation of medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures under the auspices of the applicable health benefit plan which includes pre-certification, concurrent review, continued stay review, discharge planning, management of denials and appeals, management of length of stay while maintaining compliance with regultory requirements. Serve as a resource for physicians, nurses, social workers, and other ancillary staff in understanding criteria for continuing stay and medical quality issues. Reconcile services rendered with patient benefits and communicate with physicians and third party payers to assure appropriate reimbursement. Identifies and utilizes resources to best meet patient/family needs including community resources. Responsible for medical reviews of denied or pending claims and assist the physician and patient on appeals process. Responsible for coordination and submission of medical information requested by customers to insure maximum reimbursement. Serve on the Utilization Review Committee as well as Discharge Planning Committee.

QUALIFICATIONS

Education

Education Level

Education Details

Required/Preferred

Associate's Degree in Nursing or Social Work Required




Bachelor's Degree in Nursing or Social Work Preferred

Licenses and Certifications

Licenses and Certifications

Licenses and Certifications Details

Time Frame

Required/

Preferred

CM - Case Management Case Management certification Preferred

Work Experience

Number of Years

Work Experience Details

Required/

Preferred

4-6 years 5 years of experience in an acute care hospital, skilled nursing or community based care provider Required

Knowledge Skills and Abilities

Knowledge, Skills, Abilities

Required/Preferred

Proficiency

Knowledge of medical terminology, ability to read and interpret medical record documentation. Required N/A


Excellent organizational and communication skills required. Required N/A


Accountable for collaborating with nursing staff, physicians, and various ancillary departments and community resources to plan appropriate patient care across and continuum for the implementation of utilization management, discharge needs, and documentation monitoring for the inpatient population. Required N/A


Ability to work effectively with physicians, nurses, and all other healthcare providers to initiate and pace accomplishments of responsibilities with minimal supervision and resolve complex problems related to patient outcomes and activities. Required N/A


Collaborates with nursing staff, physicians, ancillary departments and community resources to plan appropriate evidenced-based care across a continuum Required N/A


Prioritizes workload of Case Management and Swing Bed. Required N/A


Participates in program related meetings, development and implementation of healthcare provider education, staff development, departmental activities and in-service opportunities Required N/A


Performs Excel reviews on staff. Required N/A


Initiates Performance Improvement projects for the department Required N/A


This incumbent interacts daily with medical staff, coders, nursing personnel, medical review company staff, financial managers, clinical quality, patients, and family members. Required N/A




SCOPE

Freedom To Act:

Problem Solving:

Impact:

Financial Responsibility: Sales Revenue Target Responsibility: Approval Responsibility: P & L Responsibility: Assets Controlled: Controllable Expenses (e.g., Payroll and other budgeted items): Total Financial Responsibility: Budget Responsibility Primary Budget Responsibility: Shared Budget Responsibility:

Requirements

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No additional requirements from any stated in the above description.
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Education

You must have the following education to apply:

You must have a Associates or higher