PRIMARY FUNCTION:

To manage the daily operations of longitudinal care management, precertification, appeals and denials for patients in the acute care setting.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Evaluates and provides feedback/recommendation of information technology software that allows for comprehensive, longitudinal care management of an identified population of patients.
• Facilitates the development of care management guidelines, algorithms and protocols
• Develops and implements applicable care management processes, policies, and procedures..
• Manages daily operations of the Care Management Team
• Prepares and reviews annual performance appraisals with employees.
• Develops systems and processes to effectively manage collaborative relationships with external third party payers
• Identifies areas of potential compliance risk and develops strategies to mitigate risk in  collaboration with the Compliance Officer and staff
• Maintains strong working relationship with compliance office and staff and actively engages in all compliance activities as requested.
• Assists in the preparation of the annual operating and capital budget
• Develops processes for the accurate capture of data in order to maintain a care management dashboard reflective of key performance measures
• Collaborates with Data Informatics team to analyze data and makes recommendations for program development/changes based on data analysis.
• In collaboration with the key internal stakeholders, develops and implements processes, policies, and procedures to effectively and efficiently manage the transition of patients in accordance with state, federal and payer standards and regulations.
• Demonstrates knowledge of local, state, and federal reimbursement guidelines
• Serves as an expert resource for staff and Christiana Care leadership related to care management functions
• Coordinates and facilitates dept meetings
• Maintains a collaborative professional relationship with clinicians and administrative staff necessary to develop, implement, and evaluate successful process outcomes
• Collaborates with Physician Advisors as needed.
• Performs assigned work safely, adhering to established departmental safety rules and practices; reports, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
• Performs other duties as assigned.

DIRECTION/SUPERVISION OF OTHERS:

Assigned supervisors, case manager, case management assistants and social workers

DIRECTION/SUPERVISION RECEIVED:

Reports directly to the Director, Care Management, or Vice President, Care Management and Utilization Management
 

EDUCATION AND EXPERIENCE REQUIREMENTS:

Formal Clinical Training with professional licensure required- Registered Nurse

Bachelor's degree required Five years' experience in Utilization Management and/or Case Management,

Three years supervisory/management experience. 

Maintains required documented hours of relevant continuing education related to licensure requirements.

An equivalent combination of education and experience may be substituted.

SPECIAL REQUIREMENTS:

RN w/ Active Delaware  or compact state license. 

WORKING CONDITIONS:

Frequent travel to multiple sites as needed.  Occasional exposure to office materials.  Normal office environment.

EEO Statement: Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.