Position Summary: The individual in this position has overall responsibility for hospital utilization performance improvement and operational management of the Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure 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 Hospital 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 review processes are completed accurately and in compliance with CMS regulations and Steward 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, Ensure compliance with state and federal regulations and TJC accreditation standards, other duties as assigned.Position Qualification:Bilingual in English and Spanish preferredRequired qualifications include an active Registered Nurse license with at least two years acute hospital case management leadership experience preferred. MSN preferred. Accredited Case Manager (ACM) preferred. McKesson InterQual® experience preferred. Five years acute hospital case management experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem-solving skills and computer literacy. Business planning experience preferred. Training RequirementMust complete InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Case Management documentation system within 30 days of hire. Attendance at hospital orientation is required. Must work with regional Performance Management and Innovation (PMI) Case Management leader to complete PE Director of Case Management orientation within 90 days of hire. Primary Information, Tools and Systems Used Patient data - hospital admission, discharge, transfer systemHealthcare staff documentation related to patient careRegulatory and payor requirementsAllscripts Care Management SystemMcKesson Care Enhance Review Manager (CERMe) InterQual systemCrimsonClinical data interface and secure faxingPatient Medical Record including Cerner and HPFHospital Specific Clinical SoftwareEnterprise Reporting: Decision Support reports, PMI reportsCare DiscoveryPosition Control Communication Skills: Ability to effectively communicate in writing and orally with all levels of the organization.Must clear background and drug test required.