Manager Medical Mgmt

Responsible for managing day to day operations of the Case Managers Social Workers and Hospitalist program. Also responsible for Recovery Audit Program (RAC) Environment of Care.

• Team
  • Coordinate with Medical Management Team Members in decision making on complicated cases and insurance issues.
  • Works with Case Managers to review/appeal Recovery Audit Contractors (RAC) cases.
  • Communicates to other department Directors and leadership regarding insurance issues denials and provides feedback to Directors at all levels in the effort to eliminate risk.
  • Reviews/revises Policies and Procedures related to Medical Management Environment of Care to comply with Joint Commission and CMS standards.
  • Co-Lead Environmental Rounds of Interdisciplinary teams as indicated by Joint Commission standards.
  • When requested adjusts personal schedule to meet department/unit needs.
  • Accepts additional work assignments as assigned by supervisor.
  • Works alongside team members in case management to meet the needs of the hospital.
  • Attends/Contributes to nurse leader council.
  • Liaison to physicians in compiling with medical necessity/current standards.
  • Evaluate predictive care maps InterQual criteria Milliman Optimal Recovery Guidelines and evidence based best practice guidelines to facilitate the patient plan of care and clinical performance of medical staff to report potential quality and liability issues.
  • Coordinates daily huddles to advance care towards appropriate discharge. Collaborates to reduce length of stay 30-day readmissions and safe patient discharges.
  • Acts as a resource for hospital in the resolution of utilization and resource management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
• Service
  • Responsible for overseeing the Medical Management Department. Reports to UR committee as needed.
  • Working with the Hospitalist program and assisting with issues that arise in the day-to-day operation.
  • Facilitate and Coordinate RAC appeals.
  • Responsible for coordinating collection of denials or other insurance issues from Cerner or information system sources. (Log)
  • Responsible for maintaining database of data elements and compiling other reports as requested.
  • Responsible for completing and reporting EOC annual report to the board.
  • Leads EOC Joint Commission annual review. Reviews/ Revised policy and procedure changes as needed to remain in compliance with the Joint Commission and the CMS standards.
  • Works with team to provide coverage of the hospital as needed to facilitate care. Coordinate schedules.
  • Engaged in activities that reflect the mission and vision of St. Elizabeth. Engaged in volunteerism.
  • Adheres to hospital policy on the usage of Paid Time Off and Extended Illness Time.
  • Reports to work on time and if necessary reports tardiness to appropriate person.
  • Operates equipment and performs job-related duties in a safe manner.
  • Responds appropriately to fire safety and disaster situations.
  • Utilizes Personal Protective Equipment (PPE) in the appropriate manner for optimal personal protection.
• Quality
  • Updates Medical Management and Environment of Care policies and procedures to comply with corporate and The Joint Commission requirements.
  • Responsible for reviewing Medical Management and EOC with AVP for trend analysis.
  • Responsible for follow-up with Directors and Medical Director on RAC cases.
  • Initiates other documents and correspondence related to RAC appeals as requested.
  • Review monthly RAC and denial data with VP for trends analysis.
  • Initiates new PI teams when needed for compliance with Joint Commission and CMS standards.
  • Utilizes time to accomplish work in an efficient manner.
  • Maintains a professional appearance according to job requirements at all times.
  • Employee shall conform to regulatory customer and organizational requirements.
  • Adheres to infection control practices.
  • Has completed required TB skin tests.
  • Evaluate and analyze Departmental/Organizational performance utilizing industry and regulatory tools and benchmarks (ie PEPPER reports) to assure efficiency and identify opportunities for improvement.
  • Develops guidelines to assure that there is continuity of care between nursing units and during transfer to other facilities as appropriate.
• Stewardship
  • Seeks opportunities to reduce waste or control/eliminate costs.
  • Contributes to cost effectiveness/efficiency awareness of benefit system and cost benefit analysis. Demonstrates ability to maximize financial outcomes associated with utilization of resources delays and denials medical necessity and level of care.
  • Oversee and evaluate the denial and appeal process with external payer certifications.
  • Evaluates the treatment plan for over/under utilization of services as they relate to cost effective delivery to facilitate appropriate reimbursement through third party payor contract.
• Growth
  • Assists in developing and implementing new programs for the Medical Management Department.
  • Attends all necessary in-services to keep up to date on hospital or web-based software changes and processes.
  • Attended all required mandatory educational sessions.
  • Assumes personal responsibility for ongoing continuing education and professional development.
  • Analyzes data prepares variance reports monitors departmental/organizational records in order to ensure prudent resource and utilization management.

• At least 5 years experience in nursing in which at least 2 years in a supervisor role.
• BSN
• Proficiency in Microsoft computer programs. Understanding of Cerner Nursing and medical documentation.
• Demonstrates ability to communicate effectively and problem solve. Demonstrates ability to oversee multiple team members.
• Current unencumbered Louisiana Licensure for Registered Nurse; Certification is preferred if without certification must complete certification within 1 year.; Certification in area of specialty OR Nursing Administration; Case Management Certification; BLS Certification.