Case Management Resume Samples

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J Littel

Jennifer

Littel

449 Nader Forge

Phoenix

+1 (555) 256 9910

449 Nader Forge

Phoenix

Phone

p +1 (555) 256 9910

Experience Experience

Boston, MA

Manager of Case Management

Boston, MA

Kozey, Gaylord and Moen

Boston, MA

Manager of Case Management

Sets team direction, resolves problems and provides guidance to members of the team
Ensures team meets established performance metrics and performance guarantees
Adapts departmental plans and priorities to address business and operational challenges
Responsible for clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Manage relationships with physician practices
Manage implementation of new physician practices and deployment of resources
Manage client relationships

Philadelphia, PA

Dir-case Management

Philadelphia, PA

Bogan-Zemlak

Philadelphia, PA

Dir-case Management

Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff
Performs follow-up assessments per Case Management Plan and/or department policy
Attends annual review and performs departmental inservices
Performs intake assessment on patient within 24 hours of admission (patients meeting screening criteria)
Keeps patient informed of progress and provides information related to disease progression
Maintains a good working relationship both within the department and with other departments
Coordinates Swingbed operations for hospital

present

Boston, MA

Director of Case Management

Boston, MA

Batz and Sons

present

Boston, MA

Director of Case Management

present

Maintaining fiscal responsibility by utilizing resources wisely, taking care of equipment, and preventing lost charges
Responsible for approving and managing the day to day local level operational budget
Ensuring patient case management plans are developed, implemented and evaluated in collaboration with attending physician
Managing and coordinating comprehensive case management services
Attends staff meeting and complete all mandatory training on time
Responding in a timely, accurate manner to assignments and requests
Ensures patient case management plans are developed, implemented and evaluated in a timely manner in collaboration with attending physician

Education Education

Bachelor’s Degree in Nursing

University of Tennessee

Bachelor’s Degree in Nursing

Skills Skills

Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner
Self –Starter with the ability to work with others in a team environment to ensure quality patient care
Demonstrated success in being able to interact with all levels of medical and administrative staff regarding quality and utilization issues
Proven leadership qualities including ability to train, motivate, manage, and supervise a staff of professionals
Ability to perform trending, forecasting and analysis of case management data and development of action plans to identify opportunities for improvement
Ability to work independently without supervision
Strong case management in acute care experience
Ability to use word processing, spreadsheet, and Dbase computer programs
Excellent verbal and written communication skills
Ability to speak, read, write, and communicate effectively

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Case Management Manager Resume Examples & Samples

3+ years of Managed Care experience as a Supervisor/Team Leader doing concurrent case management; 1+ year of Progressive Supervisory experience in Utilization Management Managed Care
NJ Registered Nurse (RN) or Licensed Practical Nurse (LPN)
Knowledge of all Utilization Management processes, expectations, and requirements
Experience with ICD-9 and CPT coding, medical management criteria, reporting and benefits plan designs
Microsoft Office/Suite proficient (Word and Excel)

Director of Case Management Resume Examples & Samples

Managing and coordinating comprehensive case management services
Overseeing case management Social Work staff
Registered Nurse (RN) or LCSW
Strong case management in acute care experience

Manager of Case Management Resume Examples & Samples

Assist the Director with systems, processes, and outcomes of clinical care teams and programs designed to address clinical, psychosocial, and financial needs of patients and families
Provide training, supervision and evaluation of team members
Participate in goal-setting, program planning, regulatory compliance, staff productivity and continuous quality improvement
Previous management experience in Case Management
RN, BS/BSN
InterQual or Milliman criteria and PRI Certification
Excellent organization and written and verbal communication skills

Case Management Lead Resume Examples & Samples

6+ years of experience with Java programming
6 years of experience with designing Enterprise Applications
6 years of experience with SOA
3+ years of experience with Case Management Systems, including using COTS tools, such as Pega Systems or Entellitrak
Experience in working with Web Services and Enterprise Service Bus Architecture
Experience in working with complex data models, business process management notation, and with workflow engines
Knowledge of SOA patterns
BA or BS degree in CS or Information Management
Experience with object relational mapping (ORM), specifically Hibernate a plus
Experience with Micropact's Case Management COTS tool, Entellitrak a plus
Experience with JavaScript

Head of PV Systems & Case Management Resume Examples & Samples

30%: Oversee management of Shire global safety system including maintenance of business aspects of safety system. Responsible to oversee and manage all product migrations as a result of acquisition or divestments. Identify need for and recommend system upgrades or alternate technologies to meet the business needs
25%: Oversee PVRM vendors responsible for delegated PV system activities such as AE case data entry. Also, provide strategic oversight to identify potential additional areas for outsourcing to a vendor and lead the vendor selection process to ensure qualifications and contract in place. Liaise with other departments throughout Shire to ensure proper contractual requirements and processes in place for those vendors that contribute to PV System outside PVRM
20%: Oversee day to day operations and Shire personnel including employee management such as hiring and performance management. Ensure proper succession planning in place
15%: Oversight to ensure compliant and timely submissions of individual case reports as required. Identify areas to improve qualify of information as needed
10%: Accountable to EU Qualified Person for Pharmacovigilance both in and out business hours as required. Collaborate with management and EU QPPV to ensure compliance PV System in place
Bachelor of Science Degree; graduate degree in a scientific discipline desirable
Experience in quality systems, establishing and tracking performance metrics
Approximately 10 years in industry with extensive experience in Pharmacovigilance, including solid knowledge of safety reporting in clinical trials, post marketing surveillance, case processing and reporting to Regulatory Authorities worldwide
Must have solid knowledge of FDA and EU regulations and ICH guidelines with respect to Pharmacovigilance such as expedited and periodic safety reporting and safety agreement requirements. Must have experience with industrial interpretation with respect to regulatory expectations
Must have good working knowledge of safety systems/databases and regulatory requirements

Director of Case Management Resume Examples & Samples

Bachelor's Degree in Nursing required; Master's degree preferred
Active New York State license as a Registered Professional Nurse
Certified Case Manager (CCM), Nurse Case Manager (RN, CM), Case Manager, Certified (CMC) or Certified Professional in Health Care Quality (CPHCQ) preferred
7+ years of administrative case management experience in an acute care environment

Case Management Director Resume Examples & Samples

Bachelor’s degree in management or similar field of study required
5+ years of experience in progressive management required
5+ years of experience in an acute care hospital environment with at least 2 years in a management role
2+ years of clinical experience in medical or surgery position
2+ years of experience supervising case management and quality assurance from provider or payer subdivision

Case Management Resume Examples & Samples

Manage department phones
Assignment of authorizations
Calling for 1st clinical to prep cases for UM decision making
Attaching of clinical faxes to Authorizations
Gathering and entering Discharge data
Creation of Outpatient cases
Proficiency in all Microsoft Office applications, including Word and Excel
2+ years hands on experience working in medical related field

Case Management Lead Resume Examples & Samples

Working in a dynamic, pressurized, time-sensitive environment with interaction with internal stakeholders, impacting the relationships with demanding / advanced external clients
Experience in KYC and AML including knowledge and understanding of US AML/BSA laws and regulations as well as AML trends and issues
Excellent client service skills (must have minimum of 2 years of service in a client facing role)
Strong interpersonal skills and the ability to handle conflict and manage expectations. Demonstrate high energy; be PRO-ACTIVE, extremely positive and have a ‘driver and achiever’ mentality
Excellent verbal and written communication skills. This role requires an individual to demonstrate an “Extrovert” personality type at times, who will need to be in constant communication with other HSBC units and external clients
Strong ability to prioritize multiple requests for information, while ensuring integrity, accuracy, completeness and timeliness of data
Proven ability to create and maintain good relationships is essential
Proven relevant work experience supporting Relationship Managers/Sales or working in an operational middle office or client facing support function, within the financial services industry
Ability to prioritize multiple requests for information, while ensuring integrity, accuracy, completeness, and timeliness of data
Strong computer skills, including Microsoft Excel and Word; quick learner of data websites and applications
Track record of success in a role within the professional services industry that leverages knowledge of the tax issues facing multinational US banks, mutual funds, private equity, hedge funds or REITS in the reporting space

Employment Services & Case Management Director Resume Examples & Samples

Masters in Business, Public Adminstration, Education, Social Work Adminstration or related field
7+ years of professional experience in health related position and at least 5+ years experience in senior management/supervisory position
Experience working with substance use disorders desirable
Knowledge in Workforce Development performance based programs preferred

Director Case Management Resume Examples & Samples

Oversee all related activities for the case management functions
Ensure program is providing quality outcomes at reduced costs through meeting targets for the annual operating plan/financial management
Manage the delivery of services to members, ensuring services are appropriate and cost effective
Ensure compliance with government and company requirements in the case management function
Develop and implement new procedures, regulatory filings and manage compliance issues
Develop, implement, and oversee case management policies and procedures and
Develop, implement, and maintain case management programs to facilitate the use of appropriate services and resources in order to maintain memberships

VP, Central Case Management Coordination Resume Examples & Samples

Analyzes market case management operations to evaluate performance, ensure consistency in meeting enterprise case management objectives, and to determine areas of program improvement or policy change
Reviews financial statements, trending reports, and other performance data to measure productivity and goal achievement and to determine areas for improvement as it relates to market case management
Confers with Chief of Central Clinical Programs and VP of Enterprise Care Management Central Operations and other administrative personnel to manage achievements and discuss required changes in goals or objectives resulting from current status and conditions
Acts as liaison between central and market case management with focus on maintaining standardization and cost effectiveness for all market case management teams
Monitors work flow of enterprise operational processes to ensure market case management is successful in achieving outcomes and targeted performance goals
Ensures market case management operations and policies and procedures are compliant with health plan delegation requirements, accreditation standards and state/federal regulatory agencies
Conducts regular staff meetings with market care management to ensure management teams are informed of corporate care management and organizational actions
Ensures provision of excellent customer service, monitors quality service and customer service delivery by staff and resolves customer service complaints
Ensures the timely preparation of reports, budgets, and records for dissemination to stakeholders
Effectively plans programs and evaluates accomplishments
Presents facts/recommendations in oral and written form
Analyzes facts and exercises sound judgment arriving at proper conclusions
Plans, supervises and reviews the work of professional and support staff
Applies policies and principles to solve everyday problems and deal with a variety of situations
Exercises initiative, problem-solving, decision-making
Establishes and maintains effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
Bachelor’s degree in Nursing (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a Bachelor’s degree)
Registered Nurse with current license in Texas, or other participating Compact states preferred
8+ years of progressive responsibility with at least 3 of those years at a director-level or higher position
Knowledge of federal and state laws and NCQA regulations relating to managed care, delegation, disease management, utilization management, discharge planning and complex care case management
Broad business background with strong skills and experience within a functional area; may have expertise within a specialty or sub-function
Knowledge of basic principles and practices of clinical nursing
Knowledge of referral processes, claims, case management, utilization management and contracting and physician practices
Presentation skills with ability to represent company to organizations / individuals in a professional manner
Proficient with computer software programs, to include: word processing, spreadsheets graphics and databases
50% travel (local and out of area) expected
8+ years experience in managed care and/or disease management with a minimum of 5years at a management level

Senior Director, Case Management Resume Examples & Samples

Ensure that management flow and distribution of safety information is globally consistent and reporting timelines are maintained as required by regulatory agencies
Participate in the development of pharmacovigilance agreements, contracts and MOU’s with licensees, commercial agents and business partners
Develop outsourcing/vendor selection strategies and relationships
Direct and ensure standardization of safety requirements and quality oversight both internally and externally on a global scale
Contribute to the selection and evaluation of contractors/consultants
Establish and maintain international collaboration, foster effective interactions and communications with local, regional and global Celgene staff and Global Regulatory Authorities
Ensure effective liaison with Customer Care, Patient Support, Medical Information, Product Quality, Risk Intervention, Global Compliance, Marketing Research, Medical Affairs, Clinical Operations and Registry departments both locally and globally
Global role based in Berkeley Heights, NJ
Ten (10) years relevant pharmaceutical/biotechnology industry experience, preferably in drug safety and pharmacovigilance
Ten (10) years relevant clinical acute care setting experience (post degree)
Ten (10) years management experience
Regulatory inspections experience
Mastery of global regulatory requirements for pharmacovigilance
Clinical knowledge of all therapeutic area patient populations and drug classes
Proficiency in technical safety systems and medical coding
Knowledge of signal recognition, statistical techniques and trials safety methods and outputs
Mastery of safety report processing operations and systems
Issues management
Knowledge of development of global labeling documents
Knowledge of establishment of the benefit risk profile for products
Subject matter expert for regulatory inspections

Manager of Case Management Resume Examples & Samples

Responsible for clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Current, unrestricted RN license in the State
3+ years of experience in a leadership role
Basic level of experience with Microsoft Word, with the ability to navigate a Windows environment
Medicare Stars experience
HEDIS experience
Quality or Six Sigma experience

Manager of Case Management Resume Examples & Samples

Serving as a clinical resource and coach for our Nurse Case Managers, Disease Managers, Nurse Team Leads and Non Clinical Support
Answering clinical questions from staff and resolving client issues
Providing ongoing training and education on clinical knowledge
Handling escalated issues when necessary
Providing updates and conducting meetings with clients as needed
Maintaining staff levels, interviewing and hiring employees and enforcing disciplinary actions
Conducting employee performance reviews
Conducting call monitoring and case auditing of staff, and implementing performance improvement plans
Current, unrestricted RN licensure in the state of GA
3+ years of Clinical experience as a RN, with 1+ year in hospital-based acute care
Certified Case Manager (CCM) designation, or the ability to obtain within 24 months
3+ years of leadership experience, with the ability to partner with staff to build high-performing teams
2+ years of case, and / or disease management experience
Call center management experience
Experience working in managed care or telephonic nursing
Experience managing a large staff to manager ratio
Knowledge of URAC and / or NCQA Clinical Standards
Strong people-management experience, to include motivational leadership, ability to implement performance improvement plans, and a drive to see employees succeed in their work
Proficiency in MS Word and MS Excel, to include the ability to create Word documents and Excel spreadsheets
Ability to manage to metrics
Ability to manage deadlines and task-oriented projects

Director of Case Management Resume Examples & Samples

Minimum of three (3) years of case management supervisory experience
Minimum of five (5) years case management experience in an acute care environment
Minimum of three (3) years clinical experience
Experience starting a new case management program as well as growing existing programs
Knowledge of models of case management and experience with how to transition care management functions from one model to another
Working knowledge of case management standards of practice and staffing standards in accordance with the Case Management Society of America (CMSA)
Facile understanding of all types of medical insurance and regulatory requirements; reimbursement/utilization mechanisms and rules and regulations; criteria sets (e.g. Milliman, Interqual) requirements and practices, including third party requirements
Knowledge of data-driven approaches to decision-making; experience in using systems and tools to facilitate effective care management approaches
Demonstrated success in being able to interact with all levels of medical and administrative staff regarding quality and utilization issues
Experience in working collaboratively across the care continuum, including ambulatory care providers, home care, community services, and other post-acute services
Experience in successfully working with payors regarding care transitions, payment and reimbursement as well as creative approaches to meeting patient needs with available resources
Strong interpersonal , oral and written communication skills: effective interpersonal and problem solving skills
Ability to perform budgeting and operational management reporting, including dashboards
Ability to perform trending, forecasting and analysis of case management data and development of action plans to identify opportunities for improvement
Experience in using Microsoft Office Suite, including Word, Excel and Powerpoint and Case Management tools and systems in managing a department
Office

Senior Mgr, Case Management Resume Examples & Samples

Manages and optimizes workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibilities
Serves as an instrumental partner in monitoring and tracking key performance indicators to include identification of over/under utilization patterns and/or deviation from expected results for assigned area/markets
Monitors processes and procedures to ensure compliance with contractual, regulatory (State and Federal) and accreditation entities
Provides leadership and support to front-ling staff and supervisors/manager
Monitors and tracks production and quality driven work products and outcomes to individual performers
Provides guidance for Case, Disease and Behavioral Health management for future expansion and growth efforts
Performs duties as assigned
Required Other Graduate of an accredited RN Nursing Program
Preferred A Bachelor's Degree in nursing, public health, social work or related field
Required 7+ years of experience in current case management
Required 4+ years of experience in managed care
Required 3+ years of experience in Supervisory/Management experience
Advanced Ability to effectively present information and respond to questions from peers and management
Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
Intermediate Ability to work in a matrixed environment
Advanced Ability to work within tight timeframes and meet strict deadlines
Advanced Demonstrated leadership skills
Intermediate Other Bilingual skills a plus
Preferred Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Preferred Intermediate Microsoft PowerPoint
Preferred Intermediate Healthcare Management Systems (Generic)

Director of Case Management Resume Examples & Samples

Coordination/integration of department services with the hospital’s primary function
Develop/implement policies/procedures that guide/support the provision of services
Recommend a sufficient number of qualified/competent staff to provide department services in support of provision of services
Determine the qualifications/competence of personnel
Continuously assess/improve department’s performance
Maintain/implement quality control programs
Provide for the orientation, in-service training and continuing education of staff
Recommend space and other resources needed in the provision of services
Identify and select outside sources for needed services
Attendance and being on time, ready to work your scheduled hours is an essential job function
Bachelors Degree required; Master’s degree preferred
Texas State RN license or compact license is accepted
10 years nursing, 5 years management and 2 years case management experience
Ability to listen, interact and communicate verbally and in writing

Director Case Management Resume Examples & Samples

Overseeing department/program evaluation
Ensure appropriate utilization of resources, facilities and services by reviewing admissions, duration of stay, professional services rendered for both inpatients and observation patients
Develop departmental goals
Create and implement action plans
Identify patient discharge needs and work in collaboration with nurses and physicians in managing patient care need through the organization
Supervise Case Managers

Director of Case Management Resume Examples & Samples

Coordinates the collaborative case management process
Assists with providing statistical data for Medical Staff Committees as requested, related to Utilization Review Management
Prepares reports for committees in cooperation with the Chair of the URM committee
Monitors qualitative/quantitative indicators per InterQual criteria, appropriateness of admissions and utilization of resources
Analyses data for trends of improvement and/or areas of concern and recommends appropriate actions related to case management throughout the continuum of care
Maintains mechanism to follow-up on areas of concern
Reviews patient records as requested for QI issues
Monitors for JCAHO, state and regulatory compliance related to Case management
Designs methodology for tracking review of patients for criteria and authorizations
Assists with daily self-pay flash meetings, as well as seeks resources available for the self-pay/indigent population, collaboratively with the CM’s and MD’s
Coordinates and has oversight of primarily concurrent and retrospective review of records related to patient days
Works cooperatively with Health Information Management Department’s procedure in requesting and returning records for discharge dispositions
5 to 8 years related case management experience. Minimum of 3 years hospital acute care case management experience. Successful leadership/management experience within matrixed, corporate organizations

Case Manager Psych Case Management Days Resume Examples & Samples

RN, MSW or Master's Degree in a relevant clinical behavioral sciences field (social work, counseling, psychology, etc.) from an accredited university
Current Missouri R.N. or L.C.S.W. or L.P.C. Licensure or Eligible for Licensure or Certification at the state or national level for independent practice and/or specialized therapeutic process that requires postgraduate education and licensure, certification or registration
Demonstrated competency in CPR and NVCI required upon hire or within three months of hire
Working knowledge of DSM preferred
Demonstrated knowledge or training in the developmental and emotional needs of patients in this age group

Director of Case Management Resume Examples & Samples

Demonstrates well developed problem solving, communication and interpersonal skills
Demonstrates knowledge of principles of utilization management and case management
Computer skills in word processing, excel, data analytics
Five (5) years managerial experience in Utilization Review and/or Case Management
Strong acute care clinical background
Three (3) years experience in a leadership role required
Current California Registered Nurse License
CPUR, CPUM, CCM or other national certification in Utilization Review or Case Management preferred. WORK ENVIRONMENT
Ability to work in high volume fluctuating census environment
Subject to interruptions

Divisional Director of Case Management Resume Examples & Samples

1) Assist, train and monitor progress of Case Manager designees in the following aspects of facilities managed care contract management
Maximize benefits by coordination of cost effective care, avoid fragmented care and duplication of services, and ensure the appropriate level of care is provided in the most suitable setting
Participate in all Medicare and managed care resident interdisciplinary meetings
Assist in planning the services required in the resident’s discharge plan as necessary
Maintain communication with facility business office and CBO to ensure accurate census and payment of managed care and Medicare residents
Perform random charting review to ensure accurate and thorough documentation to support reimbursement of services rendered
Assist with contract negotiations, as necessary
Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator
Report any known or suspected unauthorized attempts to access facility’s information system
Assist with pre admission evaluations of potential managed care patients, including cost-out, insurance authorization, and patient/insurance education for training purposes, as necessary
2) Have understanding of Regions Managed Care contracts
3) Embrace Consulate Health Care’s five core values of compassion, honesty, integrity, respect and passion, and incorporate them into one’s daily job function
4) Demonstrate respect and compassion in every interaction
5) Conduct oneself with the highest degree of honesty and integrity in every interaction
6) Demonstrate a passion for caring as evidenced by interaction with co- workers, residents, families and visitors
7) Perform all other duties, as assigned
Assist/train facility Case Manager Designees
Assist and participate in the admission process including pre-admission assessment, rate negotiations, benefit verification, care needs, and reporting
Assist interdisciplinary team in planning for admission and ensure staff is adequately prepared to meet needs for the managed care resident on admission
Develop and maintain a good rapport with interdepartmental personnel, as well as other departments within the facility to ensure that services can be maintained to meet the needs of the residents
Make appropriate reports to department supervisors as required or as may be necessary. Follow facility’s established procedures
Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines
Report suspected or known incidences of fraud relative to false billings, cost reports, kickbacks, etc
Must have a working knowledge of managed care rules, regulations, and guidelines

Director of Case Management Resume Examples & Samples

Masters Degree in nursing, or health care administration, or business administration
At least 3 years of case management and managed care experience
Current Massachusetts license in nursing
Strong understanding of managed care
Sound clinical judgment
Excellent function development and management skills
Relationship manager - providers, committees, payers

Supv, Case Management Resume Examples & Samples

Assists management in collaborating with Health Services, Operations and Information Technology departments to ensure full integration of case management reporting throughout the organization
Assists Case Mangers in completing comprehensive assessment and care plans to evaluate the member’s need for services
Monitors associate performance and conducts counseling/corrective action procedures when required. Identifies concerns, brings issues to management’s attention and offers suggestions for improvement
Provides significant input to performance evaluation, hiring and termination decisions for associates in work group
Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates
Provides training and guidance to new and current Case Managers regarding policy & procedure, systemic tools, workload and care plan development
Answers all questions and assists peers and management with delegated tasks or projects
Takes the lead in preparing and submitting projects, reports or assignments as needed to meet department initiatives and/or objectives
Ensures phone or team coverage due to fluctuations in staffing levels
Ensures regulatory requirements and accreditation standards are applied to all activity and reporting
Plays active role in creating, applying and utilizing accepted policies and procedures
Attends company meetings in absence of manager or director
Required An Associate's Degree in nursing or Graduation from Diploma Nursing School
Preferred A Bachelor's Degree in nursing
Required 4+ years of experience in an acute clinical care setting and/or MCO related experience
Required 2+ years of experience in current case management
Intermediate Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
Intermediate Demonstrated time management and priority setting skills
Required Intermediate Microsoft Word Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express

Director of Case Management K Sign on Bonus Resume Examples & Samples

Compliance with Tenet Case Management policies
Obtaining valid physician order prior to bed placement
InterQual reviews
Observation hours
Excess Days/ALOS
Clinical disputes - incidence and dollars
Number and type of avoidable days
Resource Utilization
At least 5 hours of CEUs per year on topics related to Case Management

Manager of Case Management Resume Examples & Samples

Manage and oversee Disease Management program in designated market or geography
Ensure compliance to all applicable regulations and DaVita policies o Monitor risk management and quality assurance compliance o Achieve financial and quality goals for membership enrollment in VillageHealth programs
Measure patient care outcomes in the program Build effective relationships with internal and external clients
Coordinate activities with DaVita VillageHealth management team, Regional Medical Directors, cross-functional departments, and others as needed
Maintain and manage relationships with key constituencies and stakeholders, including providers and health plans
Develop and maintain relationships with CMS and other entities as needed Participate in review and development of regional budget
Evaluate processes to ensure cost effectiveness and reduce operational expenses
Evaluate projects for cost effectiveness and impact to outcome expectations
Create and submit financial reports and analysis as needed Lead implementation of marketing and expansion initiatives
Maintain awareness and knowledge of regional market and trends o Identify opportunities for development and expansion of enhanced or new services
Participate in joint venture meetings as needed
Assist in and monitor implementation process; ensure deliverables and address questions and issues
May provide direct nursing care as needed Travel required: up to 50 % Teammate Management
Provide leadership to direct reports
Help direct reports overcome any organizational obstacles encountered during projects Manage all teammate employment activity such as hiring, promoting, job performance, evaluations, and disciplinary actions with appropriate approvals as required
Address teammate relations issues appropriately and escalate as necessary
Know, understand, implement, follow, and communicate to teammates all DaVita employment policies and procedures, awards, and other opportunities within company and foster a positive work environment
Facilitate teammate development (PDRs, coaching, mentoring, DaVita training, outside training); collaborate with direct reports to create professional development goals
Provide work direction for department teammates
Determine staffing plans that promote the most effective use of all teammates; ensure coverage during teammate absences
Adapt staffing as technology is incorporated Know and understand basic wage and hour laws, federal, state and local laws and regulations, Medicare, and legislation affecting employment
Review and approve time cards of hourly direct reports for bi-weekly payroll
Track overtime, attendance, and PTO Develop and conduct educational programs to keep teammates up-to-date on DaVita policies, new laws and regulations impacting work, and other information necessary to maintain teammates’ knowledge of department processes and goals
Know, understand, follow, and implement DaVita safety and security policies and procedures
Clinical outcomes and MIST documentation in adherence with VillageHealth goals and standards
Clinical performance demonstrating understanding and support of VillageHealth Core Values, Mission, and Health Plan
Teamwork and participation in regional and corporate activities
Strong communication on medical management, operational, and business related issues Minimum of five (5) years’ management experience leading and managing teams required; managed care experience preferred
Demonstrated experience managing to data driven outcomes and process improvement required
Demonstrated experience and effectiveness in change agent role
Demonstrated experience in healthcare coaching preferred Current CPR certification required CNN or CDN certification strongly preferred Intermediate computer skills and proficiency in MS Word, Excel, PowerPoint, and Outlook required

Case Management Director Resume Examples & Samples

Requires Masters Degree in Healthcare, preferably Nursing or Social Work
RN or LCSW preferred
Five (5) years of recent hospital case management experience or related experience required; healthcare management experience preferred

Director of Case Management Resume Examples & Samples

Ensures provision of quality services by maintaining appropriate resources, staffing levels, competency of staff, maintenance/and performance of equipment, physical space, and training and education of staff
Ensures delivery of high quality services and contributes to continuity of care through demonstrated use of interdisciplinary team approach to patient care. Works collaboratively with internal and external resources and agencies, physicians and all members of the interdisciplinary team in meeting stakeholder needs and organizational goals
Coordinates assessment of appropriate utilization of services, ensuring intervention as needed. Analyzes utilization data, identifies patterns and trends, and ensures information flow to appropriate committees
Ensures patient case management plans are developed, implemented and evaluated in a timely manner in collaboration with attending physician
Shares pertinent patient information with physicians, and other members of the interdisciplinary team regarding patient progress, treatment, and discharge planning as appropriate
Applies the principles of continuous quality improvement in delivery of services through assessment, measuring, and monitoring of case management processes and systems
Ensures compliance with The Joint Commission and ensures all regulatory and accrediting agencies requirements are met
Demonstrates knowledge of the occurrence reporting system and reports trends in occurrences to staff quarterly. This information is used to improve patient safety. Addresses patient safety in the Performance Improvement Plan
Ensures staff is educated on established guidelines for reporting a significant medical error or unanticipated outcome in the patient's care which results in patient harm
Ensures department responds to all service requests in a timely and accurate manner. Willingly assists physicians, patients and members of the healthcare team as appropriate
Demonstrates responsibility and accountability in ensuring department supports physician need to operate in multiple work environments and ease in accessing and utilizing services
Actively supports facility community efforts; represents the hospital in the community through participation in community organizations, agencies, speaker bureaus etc
Acts as an expert resource to senior leadership, department managers, physicians and all members of the healthcare team regarding case management practice, process and services
Models, fosters, and promotes a Service Excellence culture. Assumes responsibility and accountability for departmental implementation, execution, and practice of service excellence
Contributes to financial goals of organization by ensuring the monitoring and utilization of healthcare resources to achieve desired patient outcomes, decrease length of stay, and resource utilization
Demonstrates accountability for achieving global case management and resource utilization goals consistent with departmental and hospital objectives
Demonstrates responsibility and accountability in managing productivity standards. Continuously evaluates and assesses staff assignment and work process/design to enhance productivity and service delivery to meet stakeholder expectations and business goals
Actively monitors budget and evaluates expenditures on regular basis. Initiates recommendations to ensure department is operating within budget
Optimizes use of supplies, equipment, and services ensuring a high level of clinical care or services. Actively seeks ways to control costs without compromising patient safety, quality of care, or the services delivered
Provides leadership of the Case Management function, clinical services and programs. Ensures the selection, retention and assignment of competent workforce to ensure effective delivery of departmental services. Demonstrates accountability for maintaining and monitoring utilization of resources, department protocols, standards, policies, and practices
Manages staff performance through regular review, real time feedback and performance planning. Ensures performance reviews are conducted on time. Actively coaches and mentors staff
Provides leadership in effectively managing, facilitating and communicating organizational change. Encourages risk taking; fosters a culture of innovation and continuous improvement
Demonstrates accountability and responsibility for orienting new staff to specific job duties with particular focus on safety and infection control
Works collaboratively with community leaders to develop healthcare resources that facilitate a safe and effective discharge plan for all patients
Demonstrates personal responsibility for professional development. Actively promotes development of self and others through participation in professional organizations, educational opportunities, etc
Attends in-service presentations and completes mandatory education week, including but not limited to, infection control, patient safety, quality improvement, MSDS, and OSHA standards (PPE, First Aid and Bloodborne pathogens, Hazard Communications, Emergency Procedures and Job Safety

Case Management Resume Examples & Samples

Experience in a healthcare marketing, sales or relationship building role. RN with leadership and case managment experience consider a plus
5+ years of healthcare, business or military experience with accountability for metrics, building relationships, coaching, and P&L management with at least 3 years in a leadership level position
Proven ability to adeptly manage multiple priorities; a "gets stuff done" person
Demonstrated ability to adapt, innovate and lead in an environment that moves at a rapid pace, where change is common
Associate's degree required; Bachelor's degree in related area preferred

System Dir Case Management Resume Examples & Samples

4 years of previous RN or Social Work experience required
3-5 years previous case management experience preferred
Must demonstrate commitment and adherence to STHS's Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer
New hires as of December 1, 2009 must have BSN (or Bachelor's in related field) with master's preferred. Internal candidates without a BSN may be considered based upon a written agreement that they will obtain their BSN within a predetermined time frame after transfer to the Director position. This timeframe will be determined based on review of current educational credits and degree plan and education plan development with the System CMO. Failure to obtain their BSN within the prescribed time may result in removal from the Director position
Must have and maintain current certifications, according to unit specific needs. Certification must be in accordance with the curriculum of the AHA, for Healthcare Provider's Program (for any and all certifications applicable through the AHA program)
Familiar with basic nursing performance standards as outlined in the TX Nurse Practice Act
Membership in related professional organization preferred

Director of Case Management Resume Examples & Samples

Effectively allocates financial, physical and human resources to ensure that operations are effective and efficient
Effectively interprets and acts upon budget reports
Completes a cost/benefits analysis on business plans
Implements effective cost containment strategies
Delegates responsibility effectively
Motivates staff to be effective team members
Fosters development of Unit employees to enhance their ability to contribute to meet business goals
Holds others accountable for reaching a given standard of performance
Appropriately alters supervisory/management style to suit the situation and individuals involved
Facilitates timely performance reviews
Maintains current knowledge of managed care policies, contracts and changing market strategies, interacts with managed care contractors as needed
Participate in conferences, workshops and other professional development activities to maintain licensure and remain professionally current with advances in the field of expertise
At least 2 years as hospital Case Management experience, with a minimum of 5 years clinical nursing experience

Complex Case Management Screener Resume Examples & Samples

Monitors and Assesses Referrals: Monitors referral queues in the electronic medical record as well as the Self Referral Phone line so as to ensure timely response to requests for case management services, i.e., 24 hours (business time) of time referral is made and responds to referral source
Assesses referrals for program eligibility: Analyzes information related to referral and applies established screening criteria to determine eligibility for programs. Makes appropriate determination within 72 hours of receiving referral
Screening Data Sources: Integrates information from multiple data sources, including utilization management processes, purchaser data reports, predictive modeling reports and custom data reports from Advice Line. Applies screening criteria in order to determine program eligibility. Accurately reviews administrative data and clinical data to identify member eligibility for appropriate programs
Completes Initial Assessment: After initial determination of program eligibility for Complex Case Management, the Clinical Screener telephonically interviews potential enrollees and/or caregiver. Clinical Screener completes an established survey tool in order to further determine program eligibility. Uses high level communication skills to further probe questionable responses and obtain member/caregiver perspective. If member responses confirm eligibility for complex case management, the Clinical Screener obtains consent for program enrollment. Provides member/caregiver program description and expected time frame for contact by a Complex Case Manager. If not appropriate for Complex Case Management identifies and informs member of appropriate resource along with contact information
Referral to Programs: The Clinical Screener analyzes information collected during the screening process as well as the telephonic initial assessment in conjunction with the knowledge of all disease and case management programs in order to make an appropriate referral for enrollees to best suited program
Follow-Up: The Clinical screener provides follow-up communication as to the disposition of referral to the referral source in a timely manner (within 72 hours of referral creation). Communication includes identification of the program and the name of the assigned case manager along with their contact information
Screening Criteria Development: The Clinical Screener participates with analysts and decision-makers regarding defining, refining and revising clinical screening criteria. Makes recommendations based on experience with screening process
Performs other related duties as directed
Three (3) years of clinical experience plus two (2) years in case management required
Social Worker: Certified Case Manager (CCM) preferred
RN: Certified Case Manager (CCM) preferred
Basic knowledge of predictive modeling and its use in health care preferred

Mgr, Case Management Resume Examples & Samples

Manages and develops direct reports who include supervisory and/or exempt professional personnel including but not limited to hiring, mid-year and annual reviews, Performance Improvement Plans (PIP), terminations, etc
Manages & resolves e-mails and escalated phone issues in response to provider, staff and other department requests
Establishes objectives, schedules, and manages cost data for Case Management Department
Applies a comprehensive knowledge of Case Management to the completion of assignments
Intermediate Ability to drive multiple projects
Intermediate Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
Intermediate Demonstrated negotiation skills
Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Required Intermediate Microsoft Outlook Intermediate to high level efficiency in Microsoft Office including Outlook, Word and Excel

Coord Case Management PRN Resume Examples & Samples

Performs continuous assessments and evaluations to ensure patient is progressing towards desired outcomes
Maintains knowledge of resources and facilities available to patients and family members
Follows Standard Precautions using personal protective equipment as required
Current licensure as an RN
Minimum 5 years of clinical nursing experience

Director of Case Management Resume Examples & Samples

Develop and oversee the annual Case Management budget
Prepare and evaluate monthly, quarterly and annual reports of the Department's functions
Analyze physician utilization patterns, comparing to national and individual hospital standards. Communicate findings to Utilization Review and other appropriate individuals
Discuss denial of coverage related to Utilization Review with the Director of Quality Management. Assist with on-site monitoring reviews by PRO, Blue Cross, outside review organizations and third-party payers
Maintain a working relationship with local, state and federal agencies, recognizing the hospital's position in the community and its need for cooperation and assistance from such services

Director of Case Management Resume Examples & Samples

Accountable for clinical and financial operations of the Case Management department -
Ensuring patient case management plans are developed, implemented and evaluated in collaboration with attending physician
Responsible for the provision of quality services by maintaining appropriate resources, staffing levels, competency of staff, maintenance and performance of equipment, and training and education of staff
Promotes interdisciplinary collaboration, fosters teamwork and champions service excellence
Responsible for approving and managing the day to day local level operational budget
Assures that revenue, expenses, contribution margin and FTE's meet or exceed budgeted expectations
Prepares and submits budget and related reports; forecasts and accurately projects expenses; takes corrective action to address negative variances; identifies and proposes capital budget items appropriately -
Responsible for overseeing the education of physicians, managers, staff, patients and families related to the case management process at the local level. Participates in this evolutionary process by constantly identify future needs of current customers and/or identifying potential new customers
Progressive Experience in management ( 5 plus years)
Current RN state license (CA) active
Working Knowledge of INterQual and Milliman criteria guidelines (5 plus years)
Experience in utilization management and discharge planning ( 5 plus years)

Manager of Case Management Resume Examples & Samples

Develop and implement cost-effective and creative solutions for efficient, effective Case management delivery
In collaboration with the Director for Case Management identifies opportunities to streamline workflows that result in accurate, high quality production standards and improved results in cost savings, or outcomes measurement
Works with the Director of Case Management to act as a Case Management interface with other departments as needed regarding workflow development, system enhancement, measurement review, and process improvement
Develop effective working relationships with and provide high quality service for external and internal customers
Leadership skills and supervisory experience, including the ability to develop team performance
Self-motivated, able to prioritize multiple issues, excellent organizational skills, ability to track multiple projects/tasks and follow through as needed
Knowledge of CQI principles and ability to manage change
Ability to identify opportunities for improvements and recommend and implement innovative solutions
Able to work collaboratively with internal staff and external providers
Must be detail oriented; able to work independently in an ever changing environment

Case Management Authorizations & Referrals Specialist Resume Examples & Samples

Previous experience in a technical support or administrative position preferred
Demonstrated ability to positively handle public contacts and effectively organize and maintain workflow systems with rapidly changing priorities
Experience within a health care setting is preferred as well as demonstrated competency in working for two or more persons simultaneously
Proficient application of multiple computer software products preferred
Correct grammar, composition and English
Working knowledge of medical terminology, and coding, (e.g., ICD-9, CPT-4, HCPCS) preferred
Excellent communication skills, both verbal and written are required
Ability to work independently and effectively establish work priorities while receiving work from more than one person
Ability to maintain the integrity of confidential information
Experience in a managed care environment preferred
PC proficiency in word processing, spreadsheets, graphics, flow charts, organizational charts, and database software applications required
Microsoft products preferred (Windows, Word, Excel, PowerPoint, Access, Exchange)
Demonstrated ability to professionally handle public contact
Must have effective analytical and problem solving skills to support Case Management staff
Effectively interacts with individuals from all levels of the organization
Ability to work independently with minimal direction in a fast paced environment
For compliance - a proven knowledge in utilization management, quality management / improvement and accreditation process is required
For compliance - excellent verbal, written and presentation skills

Case Management Coord Resume Examples & Samples

Home health, PCA agency, or NJ DMAHS or MCO Care Management background
Case management and discharge planning experience preferred
Managed Care experience preferred
Self-starter and good time management skills a must
Authorizations or medical coding experience preferred

District Director Case Management Resume Examples & Samples

Frequent travel is a requirement of this job
Ability to be accurate, concise and detail oriented
Knowledge of the RAI process including the MDS, RAPs and Care Plan
Knowledge of Medicare and Medicaid (Case Mix) regulations
Ability to communicate effectively with staff, residents and their family members, and at all levels of the organization
Demonstrates basic clinical assessment skills to meet the job requirements
Basic computer skills such as email, simple spreadsheets, and data entry
Ability to work cooperatively as a member of a team
Three to five years of experience in a long term care environment preferred working directly with Medicare and Managed Care Services. Experience with the MDS/RAI process and/or case management preferred Multi-facility management experience desired
Valid RN license in the state(s) employed or Valid PT, OT, SLP, RT license in the state employed
Graduate of an accredited School of Nursing, BSN preferred or

Case Management Director Resume Examples & Samples

Resource Utilization System Management
Demonstrate in-depth knowledge of case management and resource utilization review practices
3-5 years' divisional or corporate experience in post-acute care settings
Expert knowledge of current state and federal government post-acute care regulations
Expert Leadership skills; effective organizational, delegation and time management skills
Demonstrate ability to work effectively with all levels of the organization
Demonstrate expertise in critical thinking and analytical skills
Expert clinical skills and ability to provide educational programs to all levels of the organization
Strong expertise in Medicare, Managed Care and ACO development
Proficient to expert in the use of software systems conducive to developing and presenting system deliverables including, but not limited to Microsoft Office Suite
Vendor management / business partnership experience preferred
Electronic Health Record experience preferred
Proficiency in QAPI systems preferred

Director of Case Management Resume Examples & Samples

Skills in verbal interaction and written communication including excellent communication skills with physicians
Knowledge and understanding of core measure diagnoses and management
Demonstration of adult education principles, theory, and technique
Self –Starter with the ability to work with others in a team environment to ensure quality patient care
Ability to use any and all equipment needed to care for patients
Knowledge and understanding of Medicare guidelines and regulatory requirements related to CMS

Dir-case Management Resume Examples & Samples

Demonstrates Competency in the Following Areas
Performs intake assessment on patient within 24 hours of admission (patients meeting screening criteria)
Performs follow-up assessments per Case Management Plan and/or department policy
Utilizes clinical pathways whenever ordered by physician, to facilitate coordination of patient care
Plans patient care in collaboration with all members of the healthcare team
Keeps patient informed of progress and provides information related to disease progression
Coordinates specialties when appropriate for optimal patient care
Coordinates Swingbed operations for hospital
Orders and arranges for home care equipment, healthcare needs
Works with third party payers to validate need for patient care and home care environment needs
Educates patient and family on all aspects of patient's hospitalization and continuing care
Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained in the computer database
Assumes responsibility for timely completion of required case management reports for regulatory bodies, health plans, reinsurance carriers and the PMG/IPA Board of Directors
Demonstrates an ability to be flexible, organized and function under stressful situations
Maintains a good working relationship both within the department and with other departments
Consults other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution
Functions as a patient/family advocate
Documentation meets current standards and policies
Assures patient returned from hospital to safe environment
Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services
Wears identification while on duty
Attends annual review and performs departmental inservices
Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff
Attends committee, CQI and management meetings, as appropriate
Resolves personnel concerns at the departmental level, utilizing the grievance process as required
Effectively and consistently communicates administrative directive to personnel and encourages interactive departmental meetings and discussions
Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department
Ability to read and communicate effectively in English
Current clinical knowledge
Understanding of healthcare/HMO industry
Knowledge of financial and/or statistical analysis

South Atlantic Division Director Case Management Resume Examples & Samples

Provides leadership to and actively participates with facility staff to identify, implement, or enhance Case Management programs consistent with HCA and facility strategy
Assesses Case Management and Utilization Management performance in assigned facilities
Disseminates information accurately and timely with multiple audiences; leads regularly scheduled communication sessions with facility CM Directors
Identifies process improvement opportunities; develops, implements, monitors and revises action plans
Identifies and shares best demonstrated practices; stays abreast of current practice standards; shares within division and across company; facilitates standardization where appropriate
Reviews existing policies and recommends revisions; assists with the development and subsequent implementation of new and/or revised policy and procedure; ensures compliance with all HCA policy and procedure
Facilitates the implementation and adherence to regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives related to Case Management services
Provides regulatory and compliance updates and initiates/drives process changes to ensure compliance with regulations and quality initiatives. Reports findings to appropriate corporate entities
Provides data analysis of identified case management metrics; develops, implements and monitors action plans when benchmarks are not met; educates and mentors facility case management staff on interpretation of data and the performance of causal analysis; Reports findings to appropriate corporate entities
Fosters communication and facilitates collaboration between facility Case Management and PAS as well as other departments within HCA
Assesses learning needs related to case management practice
Facilitates and assists with new and ongoing Case Management education within the division; provides or facilitates specific education related to the 4 critical functions of case management practice and process; focuses on case management, evidence-based, best-practice and regulatory compliance
Ensures that all HCA-mandated education is completed within the set time frames
Performs random open chart audits to validate that policy, procedure and standards are met; works with facility Director to develop action plans; works with Corporate Case Management and Regulatory Compliance teams prior to developing and implementing facility or division wide audits
Provides input to managed care department on utilization management activities and communicates current contract information to facilities
Provides leadership to the development of resource reduction strategies consistent with facility strategic plan within the areas of case management and utilization management with a focus on quality outcomes, reduction of length of stay, medical necessity and level of care
Provides support and leadership in implementation and oversight of the case management aspects of ESP; monitors and reports monthly ESP metrics from the ED Dashboard
Provides support and leadership in implementation and oversight of the case management aspects of the Bed Management program
Designs, implements and monitors processes to ensure facility outcomes are achieved related to managed care contracts, ensuring that a process for obtaining appropriate authorizations or determinations of medical necessity for all payers is in place; facilitates contract compliance resulting in a decrease in payer denials and avoidable days at the facility level
Anticipates and proposes opportunities to improve current technology or identify new technology to enhance performance and productivity: Leads initiatives in assigned facilities
5 years Nursing Case Management experience
Certification in Case Management, Nursing, or Utilization Review, preferred
Ability to communicate effectively in oral, written and electronic formats
Demonstrates analytical and critical thinking abilities with pro-active decision-making, problem solving and negotiation skills
5 years hospital case management experience required
2 years director/supervisor level experience
CPUR, CCM preferred

Director Case Management Resume Examples & Samples

Licensure/Certification/Registration: Current licensure to practice as an RN in the state of Louisiana or LCSW in the state of Louisiana preferred. CPR required
Education:Bachelor's degree required or an equivalent combination of relevant education and/or experience may be considered
Experience: Broad based clinical care experience in an acute care facility, minimum of 5-7 years of applicable experience in occupational field

Director of Case Management Resume Examples & Samples

Oversees team conference process and educates staff in facilitation and reporting
Leads daily case management operations meetings, represents department in hospital operations
Ensures compliance with CMS regulations and Conditions of Participations for discharge planning
Assigns patient caseload to dept members and self for optimal service delivery
Acts as a resource for case managers and other team members
Reports questionable situations, concerns, complaints or harassment immediately

Manager, Caremore Case Management Cerritos Resume Examples & Samples

Requires an RN; 4 years experience in a managed care or healthcare setting; or any combination of education and experience, which would provide an equivalent background
Leadership/Management experience required. Strong People/Team building ability required
BS in Nursing preferred. Current unrestricted valid RN license in applicable state required
Ability to provide continued presence on the job and availability to cover case management’s operational needs
Strong communication and organizational skills required
Proficient with Microsoft Office (Word, Excel, and Outlook) required
Occasional travel to CareMore Clinic locations may be required

Manager of Complex Case Management Resume Examples & Samples

Provides direct day to day supervision of staff including licensed and unlicensed staff
Preparation for case review meetings including health plan specific reviews as directed by Director of IP Management
Acute and SNF Inpatient management (reviews, denials, transfers)
Oversight of discharge planning
Works directly with hospitalists to facilitate appropriate length of stay and resolution of specialist issues
Provide ongoing educational opportunities to staff, ensuring an understanding of the business processes, technology used within the organization, regulatory compliance, program standards and outcomes
Preparation of inpatient denial letters including DENC as required
Assists with health plan audits and surveys
Develops and implements new policies and procedures
Orients / trains case management staff on case management processes and identifies efficiencies and develops / facilitates corrective action plans
Participates in IPA UMC Meetings and Provider Office Meetings as assigned
Current unrestricted RN licensure in the state of CA
2+ years’ experience preferably in the managed environment
Knowledge of Case Management, Utilization Management and Quality Management processes and principles
Knowledge of general IPA operations
Previous management and / or training experience
Complex Case Management experience
CCM - Professional Certification or License

Manager of Case Management, Sign-on Bonus Resume Examples & Samples

Manages direct reports including recruitment and retention, evaluating, staffing, scheduling, Kronos and payroll. Acts as liaison to TM&E department. Determine training needs and provides professional growth and development opportunities. Provides training, coaching, counseling and mediation to ensure staff engagement, effectiveness and efficiency. Establishes, manages, and constantly evaluates staffing levels, assignments, skills, learning needs, and deployment
Ensures compliance with all hospital regulatory, CMS/Federal and State requirements and professional standards for case management, utilization review/utilization management, discharge planning/care coordination, and transitions of care through policy and procedure development, implementation, and monitoring
Communicates as a role model for the organization’s Service Standards in performance of duties and interaction with patients, families, staff, and all disciplines
Assists Director in designing, implementing, and maintaining efficient systems and processes which promote departmental efficiency, productivity, and assure compliance with regulatory standards; controls work operations by establishing and implementing objectives, practices, and methods
Assesses and regulates staff compliance with the Hospital’s high standards for exemplary customer service and communication; promptly investigates problems/complaints and resolves when possible
Acts as an administrative liaison with third party insurers as appropriate to facilitate resolution of medical necessity determinations and fiscal denials; monitors reports, unusual incidents, patterns, and processes within the department, and recommends changes and improvements
Fosters an exceptional teamwork environment with nursing teams and interdisciplinary colleagues; coaches staff in building strong team dynamics
Meets weekly with Director and staff to share plans and ideas, and to insure employees across the department receive consistently clear information, direction, and assistance
Participates in development and implementation of appropriate patient/family education material pertinent to population served; participates in development of quality indicators and analysis of such indicators per departmental quality & performance improvement plan; identifies and implements strategies to support Hospital and departmental missions and priorities, uses evidence-based practice to initiate change and to drive improvement strategies
Assists team members to establish effective collaborative relationships with representatives of third-party payors and external health care agencies in ways that contribute to these providers’ development of an enhanced image of our hospital and health systems
Establishes stewardship of financial, material, and human resources, that assist the Director in managing resources to meet budgetary goals while responding effectively to necessary program changes and altered staffing levels. Maintain schedules and utilizes staff with flexibility so that the workloads are equitably distributed and productivity goals are met
Team rounding, and provides positive communication skills in establishing and fostering professional working relationships and uses consistent positive communication skills when offering assistance or making suggestions
Monitors, controls, and evaluates the quality and quantity of the staff effectiveness and work products; recruits, orients, coaches, develop, supervise, and evaluates direct reports that contributes to staff retention within the department. Assists all employees enhance and maximize skills necessary for great performance
Masters of Science in Nursing or relevant health related field preferred
Case Management Certification or equivalent in Case Management, American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or Certified Professional Healthcare Quality (CPHQ) preferred
Membership in case management and/or related specialty professional organization preferred
Transitions of care experience preferred
Demonstrated knowledge and understanding of laws, rules, regulations, and reimbursement regarding managed care and commercial insurance and federal and state government programs such as Medicaid and Medicare
Demonstrated leadership and organizational abilities with previous demonstration of consistency, independence, flexibility, initiative, and creativity, resourcefulness, effective written and verbal communications, diplomacy, organizational, and analytic skills
Self-directed, assertive, and creative in problem solving, systems planning, and patient care management
Skill in analyzing information, data, and problems
Ability to design and/or implement data collection tools
Competent to expert user third party case management guidelines
Competent to expert use of Microsoft Office
Demonstrated proficiency in managing software such as Cerner Millennium, Meditech, EHR/EMR, EPIC, Allscripts and other related software

Lsw-case Management Resume Examples & Samples

· LCSW/LMHC and/or LMFT
· One (1) year of Case Management experience required for an LCSW and two (2) years in an acute care setting required for all licensures
· Current FL LCSW, LMHC, and/or LMFT license required; LCSW preferred. IMPORTANT ADDENDUM: Current Case Managers hired prior to July 2016 will be required to become licensed as an RN, LCSW, LMHC, or LMFT and become registered through the Florida Department of Health (DOH) by December 31, 2018. Please note: Failure to obtain licensure with the State of FL DOH by December 31, 2018 will be deemed as failure to meeting the minimal requirements of the Case Manager position, resulting in termination of employment as a Case Manager

Supv Case Management Resume Examples & Samples

Oversees, coordinates and monitors all Case Management team clinical and non clinical team activities to facilitate integrated proactive utilization management
Functions as hands-on supervisor for daily Case Management activities including medical necessity review, initital assessments, continued stay review, discharge planning, and other duties as required
Manages and evaluates team members in the performance of various case management activities
Performs and promotes interdepartmental integration and collaboration to enhance the continuity of care for all groups and individuals for which Molina provides care
Works with the Manager to ensure adequate staffing and service levels, and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators
Maintains effective team member relations
Assists the Manager in conducting regular monthly staff meetings
Assists with selection, orientation and mentoring of new team members
Conducts performance evaluations in a timely manner
Provides coaching, counseling and employee development and meets individually with staff at least monthly
Recognizes exceptional employee performance
Completes quality audit reviews for all Case Management staff
Assists team members in improving skills, creativity and problem solving
Collaborates with and keeps the Manager appraised of operational issues, staffing, resources, system and program needs
Manages and completes assigned work plan objectives and projects in a timely manner
Participates in committees, task forces, work groups and multidisciplinary teams as needed
Maintains professional relationships with provider community and internal and external customers while identifying opportunities for improvement
Oversees staff activities to ensure compliance with regulatory and accrediting standards
Conducts self in a professional manner at all times
Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct
Acts as an information and problem solving resource for Case Management team members
Interacts with medical directors regularly, as necessary
Facilitates open and timely communication between team members, other Molina employees and external customers.Responsible for overseeing the Case Management staff focused on assisting varous groups and individuals with their health care needs to achieve optimal clinical, financial and quality of life outcomes. Monitors information daily as appropriate including member metrics and staff productivity. Evaluates the services provided and outcomes achieved by the team and recommends enhancements and/or improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and guidelines in day-to-day activities. Demonstrated ability to communicate, problem solve, and work effectively with people
Skilled at supervising high functioning teams
Able to use effective management principles
Excellent organizational skill with the ability to manage multiple priorities
Work independently and handle multiple projects simultaneously
Knowledge of applicable state, and federal regulations

Mid-atlantic Case Management, Chatham, Feb Resume Examples & Samples

Answer all incoming customer phone calls within quality standards
Capture prospect information (Name, Address, Phone, email, Product of interest, Source, CRM questions)
Answer detailed product questions on the brand, current nameplates and their performance capabilities
Define consumer needs by asking relevant CRM/Product questions
Select fulfillment items
Complete price and equips statements for consumers
Locate dealers following standard dealerization rules
Categorize callers and offer appropriate Touchpoint (i.e. warm transfers to a dealer)
Provide website navigation assistance to consumer oriented brand sites
Escalate outstanding issues
Provide Goodwill to customers on behalf of the client within the client guidelines
Ability to communicate in written form (email/text chat) with consumers regarding products and programs supported
Preferably has sales or marketing background with ability to build rapport with consumers over the phone
Conduct CRM outbound follow-up calls to ensure receipt of fulfillment items and to answer any additional questions
As required call consumers to invite them to attend events
Follow critical elements of the Minacs Call and File handling process
Stay current with Center procedures, product information and online resource tools
Appropriately managing customer complaints from initial call to resolution

Case Manager Psych Case Management PRN Resume Examples & Samples

The Case Manager is responsible for the daily clinical care coordination of the patient through their entire episode of illness within Research Psychiatric Center’s healthcare system
This includes the activities of initial assessment, continued stay review, case management, benefits management and denial/appeal management
One year experience working in a mental health setting. Previous experience in mental health utilization or clinical case management preferred
Knowledge of Community Resources/Services required

Director of Case Management Resume Examples & Samples

Portsmouth has an average of 750 discharges per month
The position has 12 case managers as direct reports
Top Priorities: Length of stay, working with outside rehab facilities, and with physicians on any barriers
Assures that appropriate application of the rules of severity of illness, intensity of service, medical necessity evaluation, discharge planning, admission and concurrent review, denial and appeal process, alternate care analysis, and patient/family education including alternatives occurs timely
In collaboration with the VP or Quality and Risk Management responsible for the development and documentation of utilization management strategy and annual goals
Leads the hospital in the development and application of proactive, streamlined case management strategies throughout the hospital, including appropriate status assignment, reduction in overall LOS, and appropriate LOS; promotes optimal movement of patients throughout the continuum of care. *
Networks with extended healthcare community (community agencies, post acute care/rehab, long term care, vendors, etc.) to facilitate patient care goals; including but not limited to managed care agreements, housing, financial and psychosocial/educational needs, home medical equipment, and the decrease of readmission rates
Assumes responsibility for communication and education regarding patient flow and case management activities in the organization, as well as the medical community and governing body; and serves as a resource to facility employees and leaders
Responsible for training and compliant utilization of all documentation software; assures documentation is consistent, comprehensive, appropriate and accurate
Responsible for and provides direction to the Utilization Review Committee, as well as other committees/task force activities as assigned
Leads departments within defined financial parameters
Plans, coordinates and monitors comprehensive QI programs as indicated
Represents and supports the facility during Division activities, initiatives and conference calls

Case Management Wekend Resume Examples & Samples

Current/Active NC RN License OR
3 year's experience in Case Management/Utilization Review/Discharge Planning
Ability to understand and communicate effectively with a diverse population

Case Management Manager Resume Examples & Samples

Advanced word processing and spreadsheeting skills
Five years care management experience, including at least 2 years overseeing patient insured by a managed care organization and 2 years significant management experience
Demonstrates excellent communication skills, oral and written
Demonstrates strong interpersonal skills
Demonstrates ability to work in a fast paced, high pressure environment
Demonstrates ability to prioritize, organize, trouble-shoot, and problem solve
Demonstrates a sound understanding of customer service principles and practices

Case Management Consulant Resume Examples & Samples

Improve the quality outcomes for the individual case managers on your assigned team
Build strong relationships with your regional CMC peers, trainers from Learning and Development and Practice Excellence, working in partnership with them to address learning and development opportunities
Strong relationships with your regional CMC peers, trainers from Learning and Development and Practice Excellence, working in partnership with them to address learning and development opportunities
Exhibit solid communication, organizational and people skills in order to effectively drive positive case management outcomes
Ensure a client focused approach permeates in your coaching as you act as the primary coaching resource for your assigned team, support staff in achieving overall office targets, workload management, difficult cases, department workflow and processes
Contribute to the ongoing business retention and growth by cultivating excellence in your team
Coach your assigned team on Outcome Focused Case Management, to develop and refine their skills on the appropriate utilization of tools/approaches, portfolio management, forecasting, workload prioritization with the goal of improving the overall measured team performance
Support integration of Sun Life’s group disability philosophy, policy and procedures developed through collaboration of Practice Excellence, Learning and Development and the regional group disability operations
Work with manager to identify and close any gaps on case management deficiencies that surface through coaching
Provide feedback and direction to the Abilities Case Manager on continuously improving their case management skills
Evaluate progress and provide feedback to the Manager and Director, Group Disability
Customize coaching based on the learner’s experience and responsiveness to training
Report on emerging trends so that they can be addressed and where suitable, learnings can be leveraged nationally
Partner with other CMCs and trainers to facilitate training sessions within the region, where appropriate

Manager, Default Case Management Resume Examples & Samples

Plan the operation and workflow for the SPOC function to ensure objectives are met
Organize the team, the production of the work, training and resources needed to accomplish desired and required outcomes to meet objectives
Provide employees with enough guidance, direction, leadership and support to ensure they are able to accomplish their objectives
Monitor the plan to ensure it is being carried out in a manner that assures objectives are met
Ensure cost per loan budget is not exceeded. Develop and implement strategies and tactics to reduce cost per loan expense
Ensure proper execution of homeowner assistance programs offered by investors and insurers including the Treasury’s Home Affordable Modification Program
Ensure SPOC Case Managers maintain appropriate training and certification to meet all regulatory and investor program requirements including, but not limited to mortgage delinquencies, loss mitigation, foreclosure and bankruptcy
Develop, maintain and communicate procedural and operational materials
High School Diploma or equivalent required. College degree preferred
Minimum of five (5) years of experience in the mortgage industry, collections or a customer service environment required
Minimum of three (3) years of experience in a leadership capacity required
Experience with mortgage default, foreclosure or loss mitigation preferred
Rapidly adapts to changing information, conditions and/or unexpected obstacles
Operates effectively in a team environment as well as independently
Ability to perform in ambiguous situations
Ability to jump in, figure things out and add value
Proficiency with Mortgage Servicing Platforms (e.g. Black Knight, LPS, etc.) preferred

Director Case Management Resume Examples & Samples

Develop and implement the philosophies, policies, procedures and goals for the Case Management Department
Train and develop the Case Management staff and motivate them to accomplish department goals and objectives
Provide information regarding changes in Medicare regulations and documentation issues to physicians and others as needed
Maintain Prospective Payment System, monthly case log and other files needed for peer review organization and specific needs of the hospital
Bachelors degree in clinical area required. BS in Nursing preferred. Eqivalent combination of education, training and experience
Current healthcare professional licensure as Registered Nurse, Respiratory Therapist, Physical Therapist, Occupational Therapist or Social Worker required
Appropriate certification in Case Management preferred for example: Commission for Case Manager Certification (CCMC) Association of Rehabilitation Nurses (ARN) certification
Minimum three (3) years experience in Hospital Case Management. Should be knowledgeable in TQM/QI and have recent experience as a Case Manager in insurance, workers compensation or medical management

Utilization Management Specialist Case Management Mount Carmel St Ann s Resume Examples & Samples

Participates in new associate orientation and training. Maintains RAC database and provides monthly RAC and denial updates to the department. manager, finance department and organizational integrity. Makes recommendations with the support of the department manager and the physician advisor whether to appeal or close RAC denial cases
Collaborates with revenue integrity, compliance, billing and coding to ensure that cases are coded and billed appropriately in accordance with federal rules and regulations
Works in collaboration with the secondary level review and physician advisors on cases to ensure correct level of care assignments. Monitors high dollar observation cases daily and follows up on observation cases daily with the UR case manager
Graduate from school of nursing with current license to practice in the State of Ohio; baccalaureate required
Licensure / Certification: Nursing License through the State of Ohio
Minimum of five years' experience in Utilization Review and proven experience in effectively monitoring associate performance and coaching to improve productivity and achieve business results

Director of Case Management Resume Examples & Samples

Oversee entire Case Management operation and ensure it functions efficiently and smoothly
Serve as liaison with the Office of Refugee Resettlement (ORR) and with UC home country consulates
Liaise with ORR/DCS Policy and Procedures Compliance Coordinator for updates or changes to ORR policy that affect Case Management operations
Report any ORR policy changes or updates to the Lead CMs to distribute to their teams
Serve as morale-booster for the entire department – bear overall responsibility for promoting a positive and highly efficient environment
Conduct random spot checks in UC portal to ensure Case Managers are updating UC case files in accordance with ORR policy and regulations
Certified/Licensed as a Qualified Supervisor
Experience training and managing a large team of case managers and youth care workers

Senior Persec Case Management Spec Resume Examples & Samples

Manage, track and report on the progression of adjudications files from initiation through completion
Perform quality reviews of Personnel Security Investigation actions and supporting documentation
Report on any issues that require additional investigations to ensure that cases are forwarded to the proper authorities
Create and maintain metrics for activities
Assist in evaluating collected data to compile written and/or verbal reports
Conduct file maintenance to include purging, imaging and archiving; database entry and quality control
Provide operational, technical assistance and advisory services in accordance with the Personnel Security policies, procedures and controls
Provide customer liaison with all levels of customers both internal and external
Provide telephone and written status checks, in accordance with data provided by internal and external personnel security databases
Provide operational-level technical and editorial assistance to the Division Chief as required to respond to assigned tasks to include writing/editing materials to fit defined document templates and standard guides as required
Work collaboratively with technical staff to produce accurate and quality documents for delivery to variety of senior level management and customers
Familiar with personnel security databases (e.g., DCII, JPAS, and Scattered Castles)
Use the utmost discretion to protect all sensitive and Personally Identifiable Information (PII) in accordance with current policies, directives and procedures

Case Management Resume Examples & Samples

Graduate from an accredited school of Nursing or graduate from an accredited college or university with a minimum of an Associate’s degree in a clinical healthcare field
Must maintain current licensure in a clinical healthcare field
Two years of clinical experience
Thorough knowledge of provider requirements for admissions, transfers, and discharges
Must have ability to communicate (written and verbal) well and interact with multiple health care professionals, including medical and allied staff
Organizational and problem-solving skills, as well as the ability to work independently, and as a team member needed
Must be able to work well with ill, disabled, elderly, and emotionally distressed patients/families
Three years of clinical experience
One year of Utilization Management-review and Discharge-planning experience

Manager of Case Management Resume Examples & Samples

Facilitates program development in coordination with the medical directors to ensure a unified approach to case management, and to optimize the continuity of care for patients in the neighborhood
Meet with IDT teams weekly to review patient progress in medical treatment. Identify patients that will require a physician visit and assigned IDT resources are working towards optimal performance
Develop neighborhood plans of care that incorporate medical, social, emotional and life planning goals in order to reduce unnecessary burden of illness for the patient and assist to guide them to the next level of transitions of care
Evaluate weekly metrics on completion of required home care compliance, RAF, HEDIS and complaints in the neighborhood
Provide the clinical staff with on-going clinical education / updates to enhance understanding of acute and chronic medical conditions and follow evidence based medicine
Participates in the development of outcome measurement tools and statistical reports to monitor effectiveness of the Primary Care for Complex Community Based program system. The emphasis of this position is to focus on clinical outcome of the patient’s assigned to the neighborhood
Ensure task completion, medication refill orders and provider directed home care orders are completed within LEAN standard goals and as per SMA approved nursing approved protocols
Ensure and document patient goals of care, progress notes and other record requirements in the electronic medical record
Oversees the personnel assigned to the neighborhood and complete annual and periodic performance reviews to include successful productivity standards, bonus criteria, patient satisfaction and positive outcome measurements
Collaborate with the operational team to assist in hiring, disciplinary action and competencies of the team members in the neighborhood
Review RCC call logs and notes on patient activities of the neighborhood patients
Performs duties within state and federal regulatory guideline, Optum / United policy and in accordance to scope of practice
Other duties as assigned to for program meetings / task forces in accordance with job description
High school diploma and / or equivalent
Active unrestricted Nevada RN license by the Nevada State Board of Nursing
Bachelor’s degree in nursing, public health, or other related field
Comprehensive knowledge of medical management principles for case management and preferred knowledge of insurance products lines of business
Strong knowledge of the community health care environment, the provider network and the managed care contracting processes
Good understanding of managed care systems, quality improvement and risk management
Demonstrated excellent clinical management, leadership skills and communication skills
5+ years of medical/nursing experience
1+ years leadership experience, preferably in home care
Preferred CCM certification

Director of Case Management Resume Examples & Samples

5 years of clinical experience in Case Management, Utilization Review or Discharge Planning
Ability to use word processing, spreadsheet, and Dbase computer programs
Familiarity with third party insurance billing policies and procedures
Certification in Case Management

Director of Case Management Resume Examples & Samples

Answering the telephone
Providing information
Smiling, making appropriate eye contact, and giving undivided attention to customers
Conducting yourself professionally
Responding in a timely, accurate manner to assignments and requests
Maintaining fiscal responsibility by utilizing resources wisely, taking care of equipment, and preventing lost charges
Solving problems, meeting needs, and determining what can I do to make a positive difference
Adapting to changes in a positive, professional manner
Attends staff meeting and complete all mandatory training on time
Does not incur unapproved overtime, arrives on time and leaves on time and has few unscheduled absences

Global Head of Case Management Resume Examples & Samples

Working with the global client on-boarding teams to implement the new operating model driving consistency and operational excellence
Delivering thought leadership and the day-to-day management of the global function demonstrating accountability for achieving a truly global case management function whilst driving efficiency and process improvements
Ensuring client on-boarding (new and extensions) and event driven review pipelines across CIB are appropriately prioritised with the business ensuring that the client due diligence activities are completed in line with client and business expectations
Acting as an escalation contact for day to day issues from the global teams and business
Ensuring teams operate in line with the firms governance and oversight for risk and controls
Reviewing industry best practice and tools to ensure improvements for clients on boarding experience
Building and maintaining strong working relationships with the front office sales teams and business managers
Participating and contributing to audit and regulatory topics
Applying knowledge and experience in the development and implementation of organisation wide strategy and the impact on structure and operating model
Responsible for ensuring that cases are managed effectively and consistently in line with the agreed process; ensuring that all aspects of delivery are running effectively and if necessary, escalating issues
Acting as a role model in relation to the values and beliefs and manages the function in line with internal policies and guidance and regulatory requirements
Driving continuous improvement of people, process and technology
Review complex KYC cases and ensure appropriate escalation to internal teams such as Anti-Financial Crime (AFC) and Legal
Previous experience in leading and managing Client On-boarding functions
Solid understanding of client due diligence processes and client lifecycle management including KYC, tax and regulatory obligations
Deep understanding of KYC, Foreign Accounting Tax Compliance Act (FATCA) and other regulatory requirements
Proven track record in leading a team through a change curve operating in virtual global teams and a matrix organisation
Strong interpersonal, analytical, problem solving, negotiating, influencing, facilitation, organisational, prioritisation, decision-making, and conflict resolution skills
Collaborative communication style
Educated to bachelor’s degree level, or equivalent qualification or experience

Case Management Resume Examples & Samples

Performs admission review on all inpatients. Attends daily patient rounds and shares professional knowledge, making appropriate recommendations regarding clinical and programmatic needs of patients as it relates to professional knowledge base and existing treatment criteria
Participates in individual patient care meetings with multidisciplinary team members and the patient/family to evaluate progress and to identify and resolve problems that may interfere with a positive patient outcome
Assesses discharge planning needs to ensure a safe, timely and efficient discharge. Identifies variances during the patient's stay in order to evaluate and improve processes that affect the efficiency and quality of patient care
Arranges for community services (including short and long-term placement) prior to discharge to meet patient's needs with recognition and documentation of patient choice of service providers. Demonstrates effective use of these resources within established reimbursement guidelines
Maintains knowledge and awareness of mental health laws regarding patients' rights and voluntary/involuntary commitment proceedings, coordinating such proceedings with necessary personnel
Maintains appropriate, timely, and effective communication with patients, families, community agencies, physicians, nursing staff, department managers, ancillary departments, and the Manager regarding variances, aspects of patient care management
Maintains clinical records of all patient contact and clinical reviews, according to hospital policy and other regulatory guidelines (i.e., State, JCAHO). Documentation is completed in a professional and timely manner and includes interventions, recommendations, and referrals

Case Management Coord Resume Examples & Samples

2 years of Case Management experience (REQUIRED)
Managed Care experience (preferred)
2 years experience in behavioral health, social services or appropriate related field equivalent

Manager of Case Management Resume Examples & Samples

Assists in developing specific short and long-range programs and project plans to obtain the facility objectives
Partners with the CM Director in planning and coordinating Case Management activities, is involved in operational efficiency and effectiveness as well as major impact on all other hospital areas
Effectively interviews and selects a qualified number of personnel as required to meet department objectives. Ensures hiring practices conform to appropriate Affirmative Action/EEO practices and regulations
Provides direction to the Case Management staff. Reviews performance of the department staff. Assists with appropriate disciplinary action and performance improvement of staff members as needed
Oversees projects assigned to the manager and directs resources to ensure the attainment of facility goals
Shares responsibilities with CM Director for ensuring the department meets and adheres to all applicable federal, state, JCAHO, and local regulatory agency requirements and for ensuring the department and facilities success in any regulatory survey
Participates on various committees and other task forces as assigned by CM Director and completes all assignments related to such
Participates in regular discussions and reviews on a variety of diverse/complex issues including financial matters, which have hospital-wide impact
Add input on decision making that is required to maintain acceptable operations based on strategic goals and policies. Displays ingenuity and foresight in determining the most appropriate solution in the absence of established guidelines
Confers with others when necessary to resolve procedural difficulties, clarifying department responsibilities, objectives and resolving identified problems
Responsible for special projects as assigned by the CM Director. Meets all objectives as set forth in individual evaluation and displays a good work attitude towards job responsibilities
Adheres to hospital/departmental attendance policy, work hours and maintenance of personal appearance as stated in facility policy
Maintains consistent record of regular and punctual attendance through daily oversight of Kronos. Creates and maintains department schedule in a timely manner
Identifies and transmits system issues impacting patient care to CM Director and to Administration
Assists in developing and educating as needed to support new regulations, software installation, changing environment, and needs of team
Monitors staff caseload and audits staff job responsibilities
5 years of Case Management experience preferred

Case Management Reviewer Specialist Resume Examples & Samples

Under the direction of the Director of Case Management, the Utilization Review Specialist is responsible for completing medical necessity reviews
Using clinical knowledge and experience, the Utilization Review Specialist reviews provider requests for medical necessity documentation/clinical review, working closely with nurses, case managers and providers to collect all information necessary to formulate a thorough medical necessity review. It is within the reviewer’s discretion to send requests for additional information and /or request clarification. In addition to the application of the non-physician reviewer guidelines, the Utlization Review Specialist formulates a “stand alone narrative “ review for each case
The Utilization Review Specialist uses his/her professional judgment to evaluate the request to ensure that appropriate services are approved, recognizes care coordination opportunities and refer those cases as needed
Ensures accurate documentation of clinical information to determine and support medical necessity criteria ,level of care and contract benefits
Responsible for concurrent queries from attending and treating physicians for documentation specificity
Utilizes allocated resources to support review determinations
Identifies and makes referrals to appropriate staff/department (Medical Director, Case Manager, Compliance, Quality, Peer Review, etc.)
The Utilization Review Specialist will maintain current knowledge and understanding of the laws, regulations, guidelines (MCG, etc.) and policies that pertain to the organizational unit’s business and uses clinical judgment in their application
Paid time-off

Manager, Complex Case Management Resume Examples & Samples

Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity
Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority
In collaboration with the Director, assists with focusing activities toward a strategic direction as well as develop tactical plans, drive performance, and achieve targets
Ensures that team members are clinically competent and adequately trained in motivational interviewing and other engagement techniques in order to achieve the market’s engagement and clinical targets for assigned population. Ensures on-going staff development through education and opportunities for professional development
Reviews department performance in relation to established metrics and implements changes in collaboration with other multidisciplinary team managers to effect continual improvement in the services provided
Leads/participates in both departmental and interdepartmental workgroups to continually enhance the delivery of programs and services and proactively respond to changing client and market expectations
In collaboration with the Director, participates in preparation of department budget. Makes budgetary recommendations and projections. Monitor, verify, and reconcile expenditures of budgeted funds. Identify cost savings opportunities within the department and/or operations
Ensures that all services are delivered consistent with applicable internal policies and procedures as well as applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management
Excellent interpersonal and communication skills and the ability to work in a matrix management environment
Strong analytic skills with ability to interpret, evaluate and act on productivity, clinical and financial data
Proficient computer skills, including Microsoft Office products. Proficiency in MS Excel and enhanced data and statistical analysis skills
Excellent interpersonal/consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
Ability to work in a high performing team environment that requires flexibility
Excellent organizational, time management and project management skills Demonstrated ability to handle multiple priorities in a fast paced environment

Director Case Management Resume Examples & Samples

Bachelor degree required. Master's degree preferred
Three to five years of experience in the field of specialty
Healthcare system experience preferred

Case Management Lead Resume Examples & Samples

Work with the business and nearshore/off-shore CDD teams to prioritize the daily on-board pipeline
Act as an escalation contact for day to day issues and periodic reviews requiring documentation from the business
Ensure teams operate in line with the firms governance and oversight for risk and controls

Case Management Manager Resume Examples & Samples

Responsible for reporting any violations of Company policies or procedures by distributors or employees in accordance with the Company’s policies and procedures related to violations
Adhere to Company policy on confidential and proprietary information
Ability to establish effective lines of communication with staff, underwriters, department heads, other sites and distribution/BGA’s
Proven track record of a Customer-service oriented approach and strong relationship management
Proactive in servicing the customer
Effective organizational skills and attention to detail
Ability to make sound and effective judgments that are based on established procedures or past precedent
Ability to effectively manage people in a professional manner under adverse conditions
Flexibility when problem solving and handling personnel matters
Tact and discretion in dealing with disciplinary actions
Bachelor’s Degree (or equivalent)
7+ years of job related experience

Market Director of Case Management Resume Examples & Samples

Bachelor’s degree in Nursing or Health Care Administration. Master’s degree in Nursing or related preferred
License to practice as a Registered Nurse (RN) in the State of Michigan
Seven years of progressively more responsible clinical experience
Five years progressively increasing healthcare management experience, including experience in Case Management operations and program development. Experience as a Case Management Director preferred
Certification in Case Management (CPUR)

Case Management Official Resume Examples & Samples

Problem solving and decision making – making timely, quality decisions
Results focus – achieving results resiliently
Planning and priority setting – getting things done effectively and efficiently
Fulfilment- Optimise technology to manage product applications workflow to completion, ensuring the highest standards in internal and external customer service

Director of Case Management Resume Examples & Samples

Requires completion of Bachelor’s nursing degree at accredited school of nursing or Bachelor’s degree in Social Work
Must maintain current AHA CPR for Healthcare Providers certification, and all hospital mandatory requirements
Must have demonstrated successful experience in management with financial responsibilities. Has a frequent interaction with physicians, nursing staff, staff in other departments, patients, families and the public. Must have the sensitivity, maturity and ability to communicate clearly and concisely
This position requires leadership abilities: professionalism, common sense, critical thinking skills, flexibility, honesty, and a service oriented attitude. Must demonstrate excellent writing skills

Director Case Management Resume Examples & Samples

Performs all duties and responsibilities as described in Case Manager job description when providing case management services
Manages caseload assignment of patients to case managers
Analyzes reports from PATCOM, UDS, and Press Ganey
Implements and educates case managers on effective utilization of the continuum of care and community resources
Completes special projects and other duties as requested to support needs of organization
Coordinates and supports hospital utilization review process
Manages core staffing plan and employs flexible staffing plan as necessary
Coordinates with other department managers to direct quality of care delivery
Participates in administrative on-call schedule and coordinates case management on-call schedule
Completes mandatory training and courses required by completion date

Optum Manager of Case Management Resume Examples & Samples

Responsible for operation and oversight of utilization management and case management activities
Supports business goals and health plan programs. Ensures that these are communicated effectively to the staff and delivered to our health plan members
Evaluates productivity and quality of programs/processes to ensure maximum performance
Collaborates with staff and leadership to develop and implement systems to support operations and business goals
Develop, manage and participate in departmental projects, workflow processes, policies and procedures in collaboration with internal and external stakeholders
Acts as a resource and supports a culture that promotes team work, relationships, professional growth, performance and accountability
Current, unrestricted RN license in Ohio
3+ years experience as a manager
CCM within one year of employment
Strong knowledge and experience in utilization management and case management principles
Ability to analyze and improve systems and expedite work required
Bachelors in Nursing (BSN)
Possess strong oral and written communication and problem - solving skills

Case Management Coord Resume Examples & Samples

Managed Care experience; preferred
Case management experience; preferred
2 years experience in behavioral health, social services or appropriate related field equivalent to program focus; required

Manager of Case Management Resume Examples & Samples

Support clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Engage in case management and coordination of care, supporting Service Coordinator team members in the field
Plans, organizes, and oversees staff to ensure timely completion of assessments
Oversees the department's daily staffing requirements to meet program standards
Implements and interprets organizational policies and procedures, reviews work of staff to ensure that policies and guidelines are appropriately applied
Other duties as assigned to support team
Current, unrestricted RN license in the State of TX
5+ years of RN experience of in a hospital setting, acute care, direct care case management, home health care or clinical experience in acute / rehab / or long term care setting
Experience in pediatric populations
Demonstrated supervisory or management experience with responsibility for team performance management
Solid experience with MS office including Word, Excel and Outlook with proficient ability to navigate in a Windows environment
Medicare and / or Medicaid experience
Experience with MDCP (Medically Dependent Children’s Program) or CCP (Community Coalition Programs)

Manager of Case Management Resume Examples & Samples

California Registered Nurse License
5 years management experience
3 years supervisory experience
Acute Care experience
Current Basic Life Support for Healthcare Providers through the American Heart Association
Bachelor of Science in Nursing with 3-5 years experience
5 years case management supervisory experience

Case Management Manager Resume Examples & Samples

3-5 years of clinical experience. Knowledge of Case Management practice as demonstrated by 1-3 years CM/UM/QM experience
Minimum of two years experience in Utilization Review/Care Coordinator with knowledge of third party reimbursement requirements
Experience with diagnosis and procedure coding

Lsw-case Management Resume Examples & Samples

LCSW/LMHC and/or LMFT
One (1) year of Case Management experience required for an LCSW and two (2) years in an acute care setting required for all licensures
Current FL LCSW, LMHC, and/or LMFT license required; LCSW preferred. IMPORTANT ADDENDUM: Current Case Managers hired prior to July 2016 will be required to become licensed as an RN, LCSW, LMHC, or LMFT and become registered through the Florida Department of Health (DOH) by December 31, 2018. Please note: Failure to obtain licensure with the State of FL DOH by December 31, 2018 will be deemed as failure to meeting the minimal requirements of the Case Manager position, resulting in termination of employment as a Case Manager

Case Management Coord Resume Examples & Samples

At least 1-2 years experience in behavioral health, social services or appropriate related field equivalent to program focus. (2 or more years highly preferred!)
MS Office knowledge to include Word, Excel and Outlook
Strong organizational skills and excellent computer skills including toggling between windows!

Case Management Manager Resume Examples & Samples

1 35 Manages case management team. Develops, enables and motivates team members to do the work required in order to meet established productivity and quality standards. Conducts team meetings, individual meetings, communicates with the next level manager, and communicates with peers and/ or other support personnel in the organization
2 35 Plans, organizes and assigns work to team members. Understands the functions and workload of the team. Manages, oversees, and monitors workload to ensure resources are appropriately allocated. Develops and maintains departmental staffing models. Establishes and communicates an escalation process. Promotes and creates a results oriented culture
3 15 Supports ongoing strategic efforts to maintain favorable ratings amongst key IMO groups, and implement and improve processes in direct to consumer channel initiatives
4 10 Supports efforts and works with the Workforce Manager as needed in the day to day movement of cases for load balancing purposes
5 5 Other opportunities as assigned
1 Bachelor’s degree or equivalent professional experience, and a minimum 5 years management experience and 10+ years work experience in insurance or related industry. Financial industry designation(s), or willingness to pursue
2 Superior interpersonal skills with a strong customer service orientation; excellent negotiation skills and willingness to make and carry out difficult decisions
3 Excellent management, presentation, and leadership skills
1 Managing Team Achievement and Results. Clearly communicates team direction by setting challenging and realistic goals. Ensures the necessary knowledge, skills, and experience are present among team members and effectively used to accomplish tasks. Can provide effective feedback at the appropriate moment
2 Maximizes team capabilities. Aligns resources to accomplish key objectives; assigns clear accountability for important objectives. Sets priorities, and is able to help employees do the same. Organizes team to maximize the use of team members and other resources
3 Delegates to employees effectively, broadens employee opportunities, acts with fairness toward direct reports, and hires talented people for his/ her team. Effectively delegates responsibility and allows employees the freedom to learn through their experiences
4 Effectively influences others in a variety of situations. Takes ideas different from own seriously; shares responsibility and collaborates with others; accepts criticism well; doesn't assume a single best way

Director of Post Acute Case Management Resume Examples & Samples

Masters of Science in Nursing
Five years' experience in Healthcare
Five years' experience in Case Management

Director Case Management Resume Examples & Samples

Prepare and monitor departmental budgets
Develops and implements programs / activities to optimize patient length of stay, assures timely patient through-put and ensures appropriate discharge planning
Provides departmental needs assessment; identifies goals, develops and implements action plans in order to achieve objectives
Maintains current knowledge of governmental regulations, contractual issues and third party payor requirements - assures departmental compliance of same
Oversees provision of direct clinical social services to areas of the Hospital served
Bachelor’s degree required, Master’s preferred
Current FL RN license
5+ years case management and discharge planning experience in an acute hospital setting
Knowledge of managed care and capitation
2+ years in a Director/Manager role over Case Management/Utilization Review strongly preferred

Manager of Case Management Resume Examples & Samples

Provides guidance to and actively participates with facility staff to identify, implement and enhance Case Management programs consistent with HCA and facility strategy
Assesses Case Management and Utilization Management performance in West Florida Division facilities
Disseminates information accurately and timely with multiple audiences; Identifies process improvement opportunities; develops, implements, monitors, and revises action plans
Assist with the development, revision and implementation of Case Management policy and procedures
Facilitates the implementation of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives related to Case Management services; validates data integrity of required and approved regulatory reporting
Fosters communication and facilitates collaboration between the facility Case Management, SSC, and other departments within HCA
Facilitates Case Management education within the division; assists with orientation and on-going education of Case Management staff, provides education related to Case Management, utilization management, collection of metrics, regulatory and compliance issues
Performs data analysis related to Case Management metrics. Develops, implements, and monitors action plans related to Avoidable Days, LOS, QIO (PEPPER reports, et al), and other identified case management metrics
Performs random open chart audits to validate policy, procedure and standards are met; works with facility Director to develop action plans to address areas of opportunity
Ensures that standards of case management practice and integrated services are developed, implemented and monitored in accordance with professional standards and regulatory requirements
Assesses learning needs related to case management practice and implements appropriate educational activities to expand knowledge base

Case Management Rep Resume Examples & Samples

Associate Degree and/or equivalent combination of education and experience
Minimum of three years experience in a professional environment with exposure to computerized systems required
Proven ability to problem solve and act independently
Attention to detail with the demonstrated ability to apply sound judgment in the application of procedure and guidelines
Communication with the Field, Home Office employees, and outside parties with a proven ability to exercise tact, diplomacy, resourcefulness, flexibility and understanding in order to foster positive long term relationships
Demonstrated organizational skills with the ability to independently recognize priorities and meet deadlines with high quality results
High degree of self-motivation and initiative in accepting responsibility for work results and contributing cooperatively to team goals
Knowledge and understanding of the insurance industry desirable
Successful completion of any required testing

Amers Commissions Case Management Lead Resume Examples & Samples

Support to bi-annual planning activities
Coordination of Compensation Design Playbook and related Credit Factoring system set-up
Support allocation/collation of Field Sales Targets and Quotas
Support allocation/collation of Field Sales Territory Hierarchy, vertical/geographic assignments and Named Account mappings
Support monthly reconciliation/approval of Commissions calculations/payments
Support Americas on tools/systems projects with respect to planning and commissions activities

Director of Case Management K Sign On Bonus Days Resume Examples & Samples

Active Registered Nurse License
At least two (2) years acute hospital case management leadership experience
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
Five (5) years acute hospital case management experience

Director Case Management Resume Examples & Samples

Knowledge/Education: Registered Nurse, Registered Records Administrator, Accredited Record Technician. Computer skills preferred
Experience: At least three years of experience in medical/surgical, critical care , or ER/or three years of health information management experience with two years of quality/utilization management or case management experience preferred or equivalent
Registration, Certification: Current licensure or certification in the State of Arkansas

Director Case Management Resume Examples & Samples

Experience Minimum Required: 5 years clinical experience with demonstrated leadership skills
Experience Preferred: Experience in post-acute settings
Education Minimum Required: ADN or RN Diploma
Education Preferred: Master’s in Nursing (MSN)
Training Minimum Required: Knowledge of health care issues, trends, legal issues, compliance and managed care with emphasis on discharge planning and care coordination
Training Preferred: Disease Management experience in program development and design
Special Skills Minimum: Ability to communicate effectively both verbally and in writing
Licensure Minimum Required: ACM, CCM, RN in state of practice

National Director, Case Management Services Resume Examples & Samples

Participates as a leader in practice management and innovation, which includes creating and enhancing current tools, methodologies, recruiting practices, and personnel development processes
Partners strategically with the Commercial Team to grow the client base, while meeting and exceeding the revenue goals
Plays a key role in the retention, professional development and performance review of staff, including mentoring, coaching, performance appraisals and recruiting
Provides guidance on development of scope of services and project plans for all Case Management related engagements
Develops and continuously improves case management core processes
Establishes appropriate key performance indicator metrics for case management services
Ensures Strategic Source accounts achieve Service Level Agreement targets
Actively participates in speaking engagements at local, state and national association meetings
Develops and maintains strong client relationships in collaboration with client success to expand current projects and identify new business, and cross-selling opportunities
Facilitates routine team meetings with team
Ensures compliance with case management standards and government regulations
Provides to VP Integrated Services regular updates to ensure client satisfaction
Travels 50% - 75% of the time, nationwide
Participates on all assigned committees deemed appropriate by organization and client
Maintains personal and professional education and growth
Responsible for maintaining continuing education credits as required by credentialing organization
Current RN licensure required
Master’s Degree in nursing, social work or a related field required
Minimum of 5 to 7 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required
Minimum of 5 years health care leadership and management experience required. Three years of case management/utilization review or related experience preferred
Current and future trends/practice in area of responsibility, policies and procedures; information systems and software used in area of responsibility
Proficient knowledge of case management regulatory guidelines required
Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful
Must display proficient communication skills, both written and verbal
Must be able to speak clearly and concisely while presenting
Ability to write reports independent of management review and with proficiency required
Experience and/or knowledge of regulatory compliance issues facing the healthcare industry are required
Requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change
Demonstrated customer-oriented management style
Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required. Focused on team and collaboration
Must take initiative to address critical issues. Ability to think critically and analytically, anticipate challenges and trends required
Must be able to demonstrate initiative and the ability to work in a fast paced environment with proficiency in multi-tasking and prioritization
Proficient knowledge of computer technology. Computer knowledge of MS Office, including Word, Excel, and PowerPoint is required
Must have proficient knowledge of automated system designs
Experience in computerized hospital/health information management systems and software applications is required
Must also have high speed internet access and experience with remote access, set-up, and troubleshooting technical issues when working remotely

Case Management Coord Resume Examples & Samples

2 years case management experience
Discharge planning experience preferred
Experience in behavioral health, social services or appropriate related field equivalent to program focus

Manager of Case Management Resume Examples & Samples

Support business goals and health plan programs. Ensure goals are communicated effectively to the staff and delivered to our health plan members
Evaluate productivity and quality of programs / processes to ensure maximum performance. Collaborate with staff and leadership to develop and implement systems to support operations and business goals
Act as a resource and supports a culture that promotes team work, relationships, professional growth, performance and accountability
RN license in the State of Nevada; CCM within 1 year of employment
Possess strong oral and written communication and problem-solving skills
Ability to contribute to the organization’s efforts to eliminate racial and ethnic disparities in organizational performance
3+ years case management or relevant nursing experience, plus a minimum of 3 years progressively responsible management experience preferably in a managed care environment
Bachelor’s degree in health care field

100

Manager, Reg Inpatient Case Management Resume Examples & Samples

Identifies need for and participates in the development and implementation of care management and utilization management policies and procedures, and ensures compliance throughout the region
Monitors the utilization of inpatient and outpatient services and ensures coordination of all ambulatory care management services with pre-admission, home health, health education and other ambulatory services
Closely monitors and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Vice President/Director, Regional Care Management regarding interventions to improve all resource management
Facilitates team process problem resolution using HCP administration, Medical Directors, Contracting, Risk Management, Behavioral Health and health plans regarding complex patient issues. Implements the results of the collaboration process
Oversees and monitors patient eligibility, financial contract accountability and health plan benefit determination for each patient referral. Facilitates resolution on areas of conflict
Prepares the department for accreditation surveys using the appropriate standards of performance. Ensures utilization management compliance with DMHC/CMS/NCQA requirements
Leads activities related to the utilization review process in conjunction with the local Care Management Committee Provider Chair
Designs, implements and facilitates data and statistical collection including outcome and quality of care information
Monitors all high risk/high cost patients in regard to care delivery, referrals, contracting, etc. Monitors provider referral patterns for appropriate utilization of specialty and ancillary services
Provides supervision and guidance to Supervisor and staff reporting to the position
Conducts monthly staff meetings including utilization management review outcome measurements and identification of training/educational opportunities
Identifies, develops and oversees the educational needs of Care Management staff, providers and others. These include an extensive orientation program, cross-training and proactive approach to case management
Identifies opportunities for the development of new care management approaches and prepares proposals with cost analyses, IS requirements, education and implementation plans
Contributes to the Care Management business plan and budget process along with the Vice President/Director, Regional Care Management
Coordinates or performs projects/activities as delegated by organizational committees and Vice President/Director, Regional Care Management
Computer literate
Proficient in Microsoft applications (Word, Excel, Access)
Knowledge of medical/nursing standards of care
Working knowledge of CMS, NCQA, DMCH, HEDIS, medical and regulatory agency guidelines
Ability to effectively collaborate with physicians, patients/families and ancillary staff
Strong oral/written analytical and problem-solving skills with ability to make sound and independent judgments
Ability to act professionally under pressure

101

Case Management Coord Resume Examples & Samples

2 years experience in behavioral health, social services or appropriate related field equivalent to program focus (Required)
LCSW (Required)
Behavioral case management and behavioral health discharge planning (Required)
Managed Care experience (Preferred)
Case management and discharge planning experience (Preferred)
Crisis intervention skills (Preferred)
Foster Care and pediatric behavioral health experience (Preferred)

102

Case Management Resume Examples & Samples

Previous utilization management, medical records, case management or unit clerk experience required
Computer literacy for entering, extracting, and compiling data and displaying data graphically
Typing skills for typing reports and correspondence
Must possess excellent communication skills with the ability to reflect Venice Regional Bayfront Health's mission and values in all situations
Must exhibit flexibility and the ability to work under pressure and without close supervision

103

Dir, Case Management Resume Examples & Samples

Utilization management concerns related to payer types and contracts
Regulatory compliance requirements for case management
LEAN performance improvement process

104

Director of Case Management Resume Examples & Samples

Experience in supervising/ managing/leading within a department or functional area. At least one year of management experience
5 years of experience in case management and or acute care
Bachelor’s degree in Nursing required if RN. MSW required if Social Worker
Proven leadership, people and communication skills
MSN, MBA, MA degrees in related field (Nursing, Social Work, etc.)
7-9 years of experience in management of case management
Certification and training in case management (ACM), CCM Certification
Licensure as required for specific functional areas (RN, MSW, LCSW)

105

Case Management Manager Altcs Resume Examples & Samples

Leads and manages a team of ALTCS case managers. Develops workflows and processes that support accurate and timely responses to issues
Develops workflows and processes that support and maintain compliance with case management standards
Promotes coordination and communication across disciplines and departments, with particular emphasis on ensuring coordinated approaches with Medical Management (MM) and Quality Management (QM)
Assists in the development of the annual Case Management Plan and review of Case Management Policies and Procedures
Conducts chart audits and reviews the consistency of member assessments and service authorizations on a regular basis
Participates in or coordinates rounds, departmental meetings, quality teams, and other committees to ensure collaboration with other departments and compliance with State mandates
Participates in or coordinates rounds, departmental meetings, quality teams, and other committees to ensure collaboration with other departments and compliance with State mandates. Promotes interdisciplinary patient care planning and patient education
3 years experience working in health care and/or working with the elderly, physically disabled and/or persons with a severe mental illness

106

Manager of Case Management Resume Examples & Samples

Current, unrestricted RN or SW license in the State of IA
Experience in utilization management, utilization review, concurrent review and/or risk management
Clinical data analysis and reporting
Leading clinical quality initiatives

107

Director, Case Management Resume Examples & Samples

Effectively directs oversees and manages the processes of Case Management , Discharge Planning, Utilization Review, Quality and peer Review. Confers and consults with federal and state agencies on matters related to Case Management
Plans and implements formal education sessions for Case Management staff on policies, procedures, regulations and mandates of federal and state agencies and Utilization and Quality Improvement Committee requirements
Initiate and coordinates control systems to identify effort and assure an accurate and efficient system
Projects a health leadership style that is participatory in nature
Manages and evaluates daily work load of the Triad Team
Leads, directs and/or educates physicians, their offices, and clinics in the practice of case management and outcomes management
Completes all projects within the required time frames
Submits frequent updates to the Chief Nursing Officer (s) on issues that affect the department

108

Director, Case Management Resume Examples & Samples

Advises sr mgmt & key stakeholders on risks & financial implications of managed enrollments and/or performance of enrollment firms &/or Lincoln Enroll
Collaborates with appropriate stakeholders to evaluate best practices & rules of engagement to accelerate our partnership & capabilities
Develops relationships with client &/or third party enrollment services firm to collaborate on educational, onboarding/enrollment solutions
Develops, maintains & analyzes enrollment metrics, to include participation level, cost efficiency & customer experience; provides complex analysis & guidance on targeting opportunities to yield enhanced participation levels
Directs & oversees the allocation of resources to meet peak demand & ensure long-term resource requirements are met
Directs team in consulting client and/or enrollment services firm/Lincoln Enroll to build and/or revise enrollment solutions to streamline processes, reduce costs, optimize employee utilization of available benefits & enhance customer experience
Directs team to obtain & analyze information on clients, their workforce & industry, and products purchased to consult & recommend the most appropriate onboarding solution including effective educational & enrollment solutions
Directs team to partner with internal stakeholders to drive renewals & inforce sales
Leads & directs team to partner effectively with clients, internal stakeholders, and/or third party enrollment firms to develop & implement appropriate (sometimes complex) educational & enrollment solutions and to ensure effective service delivery
Leads team to deliver best-in-class post-enrollment output to customers & transition customers to LFGs Service model
Leads team to effectively collaborate with internal marketing department to develop pre-enrollment marketing & communication materials
Monitors & assesses trends in enrollment & onboarding, identifies opportunities, and implements best practices to enhance customer experience & improve effectiveness of case management initiatives
Presents recommendations, builds consensus among sr mgmt for enrollment & onboarding process improvements; leads implementation of agreed enhancements to increase enrollment & customer satisfaction
Provides project management leadership for onboarding enrollment initiatives
Provides subject matter expertise to team members on complex onboarding/enrollment initiatives
7+ Years of experience in enrollment/implementation case, with 3+ years of managerial, supervisory, and/or demonstrated leadership experience(Required)

109

Systems Specialist Precert & Case Management Resume Examples & Samples

Identify, research, develop, test, approve, document, and coordinate all system upgrades and enhancements that have been defined by the Medical Affairs staff without compromising other systems. Work as a liaison between the Precert/DCO/Case Management staff and Information Services (IS) staff
Investigate problems with the applications as they are identified, determine solutions, and evaluate the need to take action. Perform the appropriate procedure to resolve the problem, which includes updating production Focus tables or sending the appropriate Production Defect or Project (Service) Request form
Lead departmental planning and requirement gathering for projects submitted regarding systems or operating environments to determine any impact to systems utilized by Medical Review. Communicate any possible changes that are needed
Ensure system changes meet the expectation of all system users and communicate changes and release dates to staff
Must be able to deal with a high degree of system complexity and detail
Ability to work on weekends, holidays, and evenings to test system problems, corrections, and modifications, as needed. Some travel to Wichita is required. Must have a valid Kansas driver’s license
Serves as the primary contact for System Specialists in other areas of the company and web design staff for testing systems that interface with the Precert system or Case Management system
Serves as the primary focal point of communication concerning changes or questions that involve systems utilized by the Precert and Case Management department
Serve as primary contact responsible for submission and signing off on Service Requests through the Serena Business Management (SBM) system
Learn and use the Project development process and apply framework to track and measure departmental projects
Responsible for entering in the Rally tool the user stories and defects needed by the IS staff for development work related to project requests and/or Production Defects
Works closely with the PMO and divisional Business Analysts (BAs) in creating the necessary Business Requirement Documents needed for any larger project work
Gives approval to install the changes, monitors the system, and conducts or coordinates post implementation testing and/or audits to validate and ensure the changes work in production as they did in test
Responsible for coordinating and implementing all system changes (to include the PAD page) and updates to the comprehensive Precert, CM, and DCO system manuals
Must be able to globally consider the impact of each system change with regard to how it will affect other systems/functionalities. Research and resolve any conflicts or negative impacts one subsystem change will have on another and communicate to staff
Work one-on-one with Medical review staff to ensure Information Services staff understands the programming needs of the user areas and review system code with the programmer
Develop test data for each request that will be utilized to document test scenarios pertaining to a specific requirement and log into the QA Complete tool (or other tools as requested by IS)
Maintain all documentation associated with testing and be able to retrieve it as required
Must be able to present relevant facts in a logical manner to internal and external customers including education to the provider community and contracting vendors (e.g. mental health, McKesson) via telephone and/or in person
Must be able to work independently, prioritize assigned work to ensure the items with a high impact are resolved first and critical deadlines are met
Must be able to key and use a personal computer up to 90% of the day. Must be able to multitask and be adaptable to all types of change. Must be able to accurately complete complex activities within assigned deadlines with minimal supervision
High school graduate or equivalent required with high aptitude in math and analytical skills
Two years experience using the principles of system testing, how to thoroughly test a system when changes occur to include setting up test cases, ensuring extreme values are tested in all cases, and verifying the results of both valid and invalid input
One year BCBSKS experience in medical review, customer service, membership or claims or one year systems experience in a physicians office or hospital
Advanced knowledge of the LAN environment, personal computers, client-server software and standard corporate software (MS Office applications including Word, Excel, and Access)
Working knowledge of ACES, MASK/Membership systems, Provider File, Precert, Case Management, and/or DCO systems, ICD, CPT, and HCPCS coding and medical and dental terminology is preferred
Must have a thorough knowledge of QMF, Access, OnDemand, BluePrints, Rally, QA Complete and Serena Business Management (SBM) Membership/Claims processing, member and provider contracts, and CSC/OTIS inquiries upon completion of training
A thorough knowledge of the external precertification processes and edits preferred
Upon completion of training, must attain a thorough knowledge of Medical Review systems both production and test which include Case Management, DCO and Precertification (internal, external, and letter processing) to include DB2 tables
General knowledge of physician and hospital operations including hospital/medical economics/practices, insurance and health products
Ability to analyze data and develop logical conclusions
Must be able to maintain a high degree of honesty, loyalty, integrity, and maintain confidentiality
Ability to type a minimum of 40 WPM preferred
Must have excellent organizational skills to handle coordination of multiple projects and work independently to meet critical deadlines
Must have excellent communication skills and the customer relation skills necessary to resolve problems/issues and interact effectively with others
Ability to translate requests for information from requestor into meaningful computer reports through independently running raw data queries from Ad Hoc data
Expected to maintain a low number of unscheduled absences. Must have a proven record of ability to report to work as scheduled

110

Case Management Services MSW Resume Examples & Samples

Initiates the case management process to ensure patients receive the appropriate level of services across the continuum. Ensures plan meets patient's clinical, psychological and discharge needs in collaboration with attending physician and interdisciplinary team
Participates in interdisciplinary team meetings to ensure optimum patient care
Develops and maintains effective relationships with appropriate community resources , post-acute care facilities and medical-equipment providers to support patient care needs post discharge
Establishes rapport and works collaboratively with insurance companies to facilitate the patients transition to an appropriate level of care
Facilitates the discharge planning process through coordination with the interdisciplinary team and serves as a liaison to safely transition patients to the appropriate level of care. Proactively identifies and resolves issues
Acts as an educational resources and provides consultation to hospital medical staff regarding discharge planning process and applicable federal, state and local regulations; identifies benefits, implications and limitations of home care as appropriate
Monitors and controls the use of healthcare resources to achieve desired patient outcomes, decrease length of stay, and decrease resource utilization. Identifies and documents delays in case and service and reports findings to department director
Utilization philosophies and practices to support Patient Service Excellence, such as AIDET, rounding with purpose, and discharge calls, etc. to optimize healing environment and patient outcomes
Tracks and trends barriers to care; Makes recommendations and develops action plans to improve processes and systems
Participates in rounding and proactively responds to patient needs to improve patient outcomes and positively impact overall patient experience

111

Manager of Case Management Resume Examples & Samples

Clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring, reporting and evaluating)
Ensures team meets established performance metrics and performance guarantee
This position will be responsible for Nursing Facility to Community transitions
1 year of experience in a hospital setting, Long Term, direct care experience or experience as a telephonic Case Manager for an insurance company
Basic level of experience with Microsoft Word and Excel, with the ability to navigate a Windows environment
Minimum of 2 years experience as a manager
Experience / exposure with Community Living Supports service
Preferred Home Health
Knowledge of CHOICES Program

112

Case Management Coord Resume Examples & Samples

Licensed Social Worker (LSW)
2+ years experience in Behavioral Health, Social Services or appropriate related field
Managed Care experience
Discharge planning experience

113

Disease & Case Management, Senior Manager Resume Examples & Samples

Bachelor degree in Nursing
Registered Nurse with current license in the State of Minnesota
Certification as a Case Manager or achievement of certification within 12 months of employment
Minimum of 6 years’ experience in health-related fields with relevant utilization review, discharge planning, and disease management, case management, or care coordination experience
Minimum of 4 years of managerial/ supervisory experience with demonstration of effective organizational and leadership skills including recruiting, hiring, training, direct supervision of employees and completion of performance reviews
Demonstrated effective, independent leadership and management skills in the development of new and ongoing medical management programs that have resulted in measurable improvement of satisfaction, clinical, and financial outcomes
Demonstrated skill and experience in effectively relating to and collaboratively working with physicians, medical administrators, and team members using a high level of working knowledge of QI, UM, benefit plans, fiscal management, and various payment methodologies. Understanding of health care and/or HMO industry
Demonstrated ability to identify and negotiate boundaries of accountability and authority within multiple disciplines and departments
Demonstrated expertise in clinical, financial, and statistical data analysis and reporting
Demonstrated flexibility, organization, and appropriate decision-making under challenging situations

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