The Case Management Manager oversees hospital case management functions, including utilization review, care coordination, and discharge planning. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective, evidence-based care across the healthcare continuum. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care.

---

The Case Management Manager oversees hospital case management functions, including utilization review, care coordination, and discharge planning. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective, evidence-based care across the healthcare continuum. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care.

---

EDUCATION: Graduate of accredited school of nursing or other healthcare professional field. Master’s degree in a health-related field, health care management or business management strongly preferred with a minimum of 3 years case management/utilization review experience or a Bachelor of Science in Nursing (BSN) with a minimum of 5 years case management/utilization review experience required.

YEARS OF EXPERIENCE: 3+ years of leadership or supervisory experience preferred, Lean/Six Sigma or process improvement experience preferred.

REQUIRED SKILLS AND KNOWLEDGE:

• Strong knowledge of payer systems, Medicare/Medicaid, and regulatory requirements.
• Participation in professional organizations and ongoing professional development relating to case management and utilization review.
• Experience with EHR systems and case management/utilization review software.
• Leadership and team development
• Clinical and regulatory expertise
• Financial and utilization management
• Critical thinking and problem-solving
• Communication (oral and written) and conflict resolution
• Data analysis and performance improvement
• Technology/systems proficiency
• Time management and multi-tasking.

LICENSES & CERTIFICATIONS:

RN Licensed to practice in the State of Ohio

Training in case management, utilization review, and discharge planning, Certified Case Management (CCM) or Accredited Case Management (ACM) strongly preferred

---

Leadership & Team Management

• Supervise and support Utilization Review Nurses, RN Discharge Planners, and administrative support staff.
• Develop and maintain job descriptions and policies and procedures to be compliant with accrediting and regulatory agencies.
• Provide coaching, performance evaluations, and staff development.
• Develop, maintain and oversee orientation plans for new staff, conducting new hire reviews according to Human Resource policies.
• Develop staffing plans, schedules, and productivity benchmarks to ensure clinical competency and patient coverage.
• Foster a collaborative, patient-centered team environment
• Create and implement action plans based upon employee satisfaction surveys and other feedback.
• Provide interdepartmental training and support on case management and utilization review requirements, tools, and processes.
• Participate in development, implementation and oversight of budget
• Represent department by presenting information in committees and workgroups.

Utilization Review Oversight

• Ensure accurate application of evidence-based criteria such as InterQual and Milliman Care Guidelines.
• Ensure timely clinical reviews and follow-up for payer approvals.
• Collaborate with Physician Advisor (PA) to ensure criteria are applied appropriately for correct patient status.
• Monitor admission status, length of stay (LOS), and medical necessity.
• Oversee payer communications and processes, including authorizations, concurrent reviews, and denial management.
• Remain current on individual payer policies.
• Collaborate with Revenue Cycle partners to analyze trends and implement strategies to reduce denials.

Discharge Planning Management

• Direct and evaluate discharge planning processes to ensure timely and safe patient transitions.
• Ensure early discharge assessments and proactive planning to support LOS and throughput initiatives.
• Oversee coordination of post-acute services (home health, SNF, rehab, hospice, DME).
• Address barriers to discharge, including social determinants of health.
• Participate in Interdisciplinary Rounds (IDRs)/huddles as appropriate.
• Appropriately intervene in challenging situations involving patients, families, physicians or others in a professional manner.

Regulatory Compliance & Quality

• Ensure compliance with Medicare Conditions of Participation and other federal/state requirements.
• Maintain readiness for audits (e.g., CMS, Joint Commission).
• Develop and enforce policies, procedures, and documentation standards.
• Lead quality improvement initiatives focused on readmissions, LOS, and patient outcomes.
• Support processes to achieve optimal clinical and financial outcomes.
• Provide input and oversight of platforms/systems for effective documentation and data tracking.

Care Coordination & Collaboration

• Collaborate with physicians, nursing leadership, finance, and ancillary departments to facilitate patient access to the most appropriate level of care across the continuum and to continuously improve quality of care.
• Participate in interdisciplinary rounds and escalation processes.
• Serve as a liaison between hospital departments and external payers or agencies.

Data Analysis & Reporting

• Collaborate with IT and data analytics partners to coordinate collection, analysis and reporting of outcomes data reflecting the effectiveness of the CM/UR department.
• Track and report key performance indicators (KPIs), including:
  • Length of stay (LOS)
  • Readmission rates
  • Denial rates and peer to peer outcomes
  • Appropriate status and observation to inpatient conversions
  • Discharge delays
• Use data to drive operational improvements and strategic planning.

Performs other duties as assigned to support the work of the department and health system.