Minimum Education

§  Requires Registered nurse (licensed in state of employment).

§  Bachelor’s Degree in nursing required, and a minimal of five years nursing/clinical experience.

§  Masters in nursing preferred.

Minimum Work Experience

§  Two years of previous supervisory/administrative experience required.

§  Previous utilization management, case management, and clinical documentation experience preferred.

Required Licenses/Certifications

§  Actively licensed in state of employment

§  Case Management certification preferred

§  CPHQ certification preferred

§  ICD-9 Coding certification preferred

Required Skills, Knowledge, and Abilities

§  Skills to effectively manage workforce

§  Strong professional, organizational, and interpersonal skills to effectively relate with all members of the healthcare team

§  Demonstrated ability to analyze, synthesize, report and manage patient care data obtained through previous quality/performance improvement activities.

§  Demonstrated written and verbal communication skills

§  Knowledge of utilization management, case management, clinical documentation concepts.

§  Knowledge of use and application of InterQual and other criteria sets to evaluate medical necessity

§  Knowledge of regulatory and compliance requirements for regulatory agencies

§  Knowledge of JCAHO accreditation standards

§  Knowledge of clinical guidelines use and tracking

§  Skills to effectively interview, select, evaluate and terminate personnel or recommends such actions needed.

§  Knowledge of utilization management process, discharge planning, case management, community/homecare resources, Medicare, Medicaid, other third party payers preferred and DRG Classification System. Requires skill to apply InterQual Criteria sets and other criteria sets.

§  Demonstrated skills in the areas of: negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis. Knowledge of clinical documentation requirements for state and federal regulations to maintain an accurate medical record.

§  Prefer a working knowledge of healthcare insurance and financial systems.

§  Experience with hospital and health plan-based case management systems preferred. Experience with McKesson STAR products a plus.

§  Prefer prior experience with managed care processes.

§  Excellent verbal and written and critical thinking skills.

§  Demonstrates flexibility as evidenced by the ability to adapt to changing priorities and regulations.

§  Computer skills preferred with knowledge of Microsoft Outlook, Word, Excel and Power Point.