The individual in this position has overall responsibility for hospital utilization management, transition management and operational management of the Case Management Department in order to promote effective utilization of hospital resources, timely and accurate revenue cycle processes, denial prevention, safe and timely patient throughput, and compliance with all state and federal regulations related to case management services. This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy Education provided to physicians, patients, families and caregivers
The individual�s responsibilities include the following activities:
Manage department operations to assure effective throughput and reimbursement for services provided
Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement
Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with CMS regulations and Tenet policy
Ensure timely and effective patient transition and planning to support efficient patient throughput
Implement and monitor processes to prevent payer disputes
Develop and provide physician education and feedback on hospital utilization
Participate in management of post-acute provider network
Ensure compliance with state and federal regulations and TJC accreditation standards, and) other duties as assigned.
Required: Preferred: BS/BSN preferred (BSN required if Magnet Hospital). MSN, MBA or MHA preferred.
Required: Two (2) years in Case Management Leadership. Preferred: Five (5) years acute hospital case management experience preferred. Business planning experience preferred. McKesson InterQual� experience preferred.
Required: Registered Nurse license. Preferred Accredited Case Manager (ACM).
Job: Case Management/Home Health
Primary Location: San Luis Obispo, California
Facility: Sierra Vista Regional Medical Center
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.