Director - Case Management

Job Summary

Oversees components necessary to maximize access to services for the patient population served. Monitors payment processing system, audits and appeals, quality assurance, and compliance functions. Serves as a resource to administration for data analysis and regulatory information for use in operational decision making. Supervises staff.

Essential Functions

• Coordinates performance review for appropriateness of patient services and care team processes according to hospital standards and policies.
• Oversees development of facility, physician, and program specific outcome reports for the purposes of performance improvement.
• Reports actions to and obtains recommendations from an Advisory committee.
• Directs the coordination of payment system processes including maintaining and negotiating outcome of system contracts.
• Coordinates quarterly compliance audits, and the audits and appeals process to ensure highest probability of appropriate reimbursement for services delivered to our persons served.
• Tracks payer reimbursement patterns to ensure accurate and appropriate payment as needed.
• Directs the clinical care coordinators who interface with payers as needed to assure payment of services.
• Provides support and intervention as needed to ensure patients are able to access required services without financial hardship.
• Performs or delegates performance of documentation audits as needed to ensure clinical documentation meets compliance standards.
• Recommends and assists with changes to documentation systems to ensure compliance with the frequently changing requirements of the division.

   

Physical Requirements
Frequent walking, standing, sitting. Ability to speak fluent English. Intact sense of sight, hearing, smell, touch, and finger dexterity. Critical thinking and ability to concentrate. Ability to lift and move reports weighing up to ten pounds. Flexibility in covering multiple sites.

Education, Experience and Certifications

Certificate of attendance to training workshop on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) preferred. Bachelor's Degree in Finance or Healthcare related field required; Master's degree preferred. At least 3 years of related work experience required.