Executive Director - Case Management, UR, & CDI

Baptist Health Care
United States, Florida, Pensacola
May 20, 2025
Job Description The Executive Director - Case Management, Utilization Review, & CDI facilitates long-term success of the Utilization Management (UM) program by providing oversight of UM at the system level. The position supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The position oversees the case management team, clinical documentation improvement team, and utilization management team of clinicians, coding professionals, physicians, and advanced practice providers to ensure accurate and timely clinical documentation in the medical record that supports the admission status and coding process in attaining sound clinical entries in the medical record. Specific management of care collaboration includes observation utilization and denial management. The position is responsible for increasing program awareness (utilization process and program benefits) to the entire hospital staff. The position must fully understand data collection and analysis for hospital use of professional services. The position supports ongoing communication and education on documentation opportunities, utilization review, coding and reimbursement issues, as well as performance improvement methodologies to physicians and entire hospital staff. The Utilization Management Review Manager functions as the UM Committee co-chair. The Executive Director works closely with organization leaders and physicians to identify documentation opportunities refine processes at the service line level. Responsibilities Maintains accountability for Utilization Management Program Success. Maintains effective and efficient processes for determining the appropriate admission status. Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status. Develops a collaborative clinical documentation improvement and utilization management teams. Oversees the Case Management team for Baptist Hospital and Gulf Breeze Hospital Provides utilization review and CDI team, physicians, administration and UM committee ongoing feedback. Assists with preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials. Develops strategies that address program initiatives and prevent denials. Facilitates the annual update of InterQual (or other screening tool) software (collaborating with Information Systems staff), creates training tools, and provides training to case management RN. Attains all agreed to goals and objectives within specified time frames, as part of the organization's overall mission. Is responsible for department's operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards. Manage team members which include orientation, development and evaluation of personnel, and monitoring the provision of delivering quality services. Participates in the recruiting, interviewing and selecting of team members following policies, guidelines and applicable laws. Evaluates their performance relative to job goals and requirements. Provides coaching to staff, recommends in-service education programs, and ensures adherence to internal policies and standards. Is responsible for the fiscal management of department; assures proper utilization of organization's financial resources. Effectively communicates departmental, organization, and industry information to staff. Qualifications Minimum Education Associates Degree Nursing Required and Bachelor's Degree Required Master's Degree Required Minimum Work Experience 5 years Clinical and/or coding adult acute care experience in Med Surg, Critical Care, Emergency Room or PACU Required 1-3 years Case management and/or utilization review experience Required 2 years Management or supervisory, leadership experience Required Required Skills, Knowledge and Abilities Excellent organizational, analytical, writing and interpersonal skills. Excellent knowledge of Word/Excel/Power Point. Knowledge of Medicare Part A and Part B. Knowledge of ICD-10, DRG and other hospital reimbursement methodology. Knowledge of regulatory environment. Understand and support utilization review strategies. General understanding of hospital-based quality initiatives. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (training provided). Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management. About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law.