Manager-Case Management

Requisition Number
Job Title
Manager-Case Management
Genesis HealthCare
Foothill Ranch
Job Description
The Manager, Case Management is responsible for the clinical, administrative, and financial oversight of the territory's center-based care management staff. This position oversees the personnel and processes necessary to ensure that the territory's network of owned and managed centers is effectively managing resource utilization, improving clinical outcomes, maximizing reimbursement, complying with contractual obligations and responding to the needs of its payor customers.
The Manager will also perform the functions of the Case Management Job Description and will be measured based on case management productivity standards.
1. Under the direction of the Director or Sr. Director, assists with the development, implementation, and maintenance of a case management model which meets the clinical and financial goals of Genesis and the operational expectations of Genesis' payor customers
2. Identifies business development opportunities which result (or may result) in improved center specific clinical and administrative capabilities and communicates them upward.
3. Develops systems which measure the utilization of services in assigned centers, identifies opportunities for improvement, provides feedback to management and assure systems in place to interface with financial and clinical outcomes.
4. In collaboration with the Director or Sr. Director, develops a formal procedure for effectively addressing concurrent and retrospective clinical and administrative denials by payors and trains staff on same.
5. Manages relationships with third party payors by ensuring timely responses to requests and by anticipating their needs with respect to each patient's course of stay.
6. Establishes standards of performance and productivity benchmarks for case management staff and ensures they are met through consistent, accurate work processes and census tracking/ monitoring.
7. Supervises, monitors and evaluates assigned staff. Oversees, evaluates, and completes performance appraisal for assigned staff. May participate in hiring of new staff under the direction of the Director or Sr. Director.
8. Identifies staff training needs related to managed care contracts and collaborates with appropriate Genesis personnel to develop the educational tools and materials that are needed to achieve care management goals.
9. Works collaboratively with the Director or Sr. Director of Case Management to update strategic business plan and ensure deadlines and goals are met.
10. In conjunction with the Director or Sr. Director, acts as case management interface with other area and corporate departments as well as external customers as needed
11. Acts as resource to staff for questions or issues in daily workflow.
12. Assist staff to secure authorizations for applicable exclusions defined by contract or obtains exception approvals for high cost medications and/or equipment. Assure exclusions are properly documented in Collections Module and communication provided to vendor when billing plan directly.
13. Provides coverage plan for team members approved or unexpected time off.
14. Works with Team Members and Revenue Cycle Management Team to reduce AR/DSO and outstanding clinical accounts as needed and generates clinical appeals when necessary.
15. Assists with and completes special projects as assigned
SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:1. Graduate of an accredited School of Nursing with current RN licensure in the state where employment occurs is required. Bachelor's Degree in Nursing preferred. Certified Case Management (CCM) or related clinical certification also preferred.2. Five to seven years of clinical nursing experience is required. Prior experience in utilization review, case management or discharge planning is required. Prior experience using evidence-based clinical decision support criteria (e.g. Interqual, Milliman) is required.3. Experience in rehabilitation nursing, acute care and/or the insurance field preferred. Five years plus full time experience in case management which includes service to short/long term facility based clients preferred.4. Management experience leading teams, groups and/or department preferred. Experience managing virtual teams a plus.5. Valid driver's license and automobile with appropriate insurance required. Ability to travel if needed. 6. Ability to adjust work schedule to changing business needs of the department.
Genesis HealthCare is an EO Employer- Veterans/Disabled and other protected categories

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