Minimum Education
Master's Degree (Required)

Minimum Work Experience
4 years

Required Skills/Knowledge
Facile with keyboarding and familiar with software such as Windows environment (i.e., Microsoft Office, Word, PowerPoint, Excel, Access).
Excellent oral and written communication skills. Knowledge of children's health issues.
Knowledge of cultural issues and their impact on health care. Strong focus on Service Excellence.
Working experience with medical management criteria such as Milliman and/or Interqual.
Ability to analyze and present productivity and outcome data using Microsoft Access and Excel.

Required Licenses and Certifications
Registered Nurse in District of Columbia.
Basic Life Support for Healthcare Provider (BLS).

Functional Accountabilities
Grow

• Encourage and share new ways of making the right work easier to do

• Recognize and share incremental improvements in operations

• Promote the success of organizational and department initiatives by clearly aligning programs to the mission

Operations Management

• Supervise and evaluate the daily work of Case Managers in accordance with departmental and organizational policies.

• Assist with Case Management staffing schedule to ensure adequate coverage and optimize productivity . Assign coverage and deploy staffing accordingly .

• Function as a resource to staff and takes steps to resolve issues that arise internally and with payors and post acute providers.

• Work directly with payors to enhance communication and improve authorization processes.

• Assist with the management of High Risk cases and tracking.

• Participates in budget development and recommends budgets for areas of oversight

• Tracks spending for areas of oversight

Education

• Provide education to the department and the organization related to payor trends, denial activity, observation status, and utilization/case management outcomes.

• Provide input and oversight to Shared Nursing Leadership's educational activities.

Relationship Building/Information Sharing

• Establish and maintain effective internal and external relationships to optimize achieving departmental and organizational goals.

• Provide information to Case Managers on organizational initiatives and professional trends in practice.

• Represent Clinical Resource Management on organizational committees.

Performance Improvement/Outcomes Management

• Ensure Case Management activites are in regulatory compliance (TJC, CMS)

• Track clinical, functional, operational, quality and financial data related to Clinical Resource Management

• Implement processes to continually improve performance, reduce denials and optimize reimbursement

• Update CRM Departmental procedures to reflect changes in payor contracts and departmental processes.