HCA, Hospital Corporation of America Manager, Utilization Review in Charleston, South Carolina
Trident Health is a 407-bed Hospital Corporation of America (HCA) hospital system comprised of two acute care hospitals — Trident Medical Center and Summerville Medical Center — and two freestanding emergency departments — Moncks Corner Medical Center and Centre Pointe Emergency. Everyday Trident Health's more than 2,600 employees, more than 500 physicians and more than 130 volunteers are dedicated to fulfilling the health system's mission — Above all else, we are committed to the care and improvement of human life. Our hope is that as you review our website you have confidence in the people who provide care to nearly 375,000 South Carolina Lowcountry residents each year.
We are searching for a new Manager of Case Management, responsible for the primary operations of the Case Management Utilization Review team including oversight of the medical necessity and appropriateness of both Inpatient and Observation patients and LOS. This manager is responsible for the implementation of processes to maintain compliance of changing regulatory insurance requirements and interfaces and collaborates with various departments, clinical services, providers and other professional staff to educate and update on issues related to status and changing regulations. This manager has oversight of appeals and RAC medical necessity appeals process and is responsible for guiding, mentoring, orienting and leading the hospital UR case management team which includes annual performance evaluations. This manager actively participates in the denial and appeal process and maintains appropriate data and reports and attends monthly UM meetings and reports out on an ad hoc basis.
A. Licensure/Certification/Registration: Current license as a Registered Nurse to practice in the State of South Carolina within 30 days of hire.
B. Education: Graduate of an accredited school of Nursing, BSN preferred.
Experience: Direct patient care experience in an acute care setting required. Ability to perform comprehensive assessment of physical and psychosocial needs of patients. Understanding of the unique needs associated with various age populations and the ability to provide age specific care and services. Computer literate. Performs in accordance with delineated job responsibilities and satisfactorily completes a yearly evaluation based on these responsibilities.
Must possess the knowledge and skills necessary to effectively meet the needs of the patient/internal & external customer.
C. Special qualifications: Desirable/Preferred: Knowledgeable about Medicare, Medicaid, TriCare and other third party payers. Direct experience with regulatory agencies and third party payers within the last two years. Experience in discharge planning and a working knowledge of alternative delivery systems including home health, durable medical equipment, rehabilitation, extended care facility and skilled nursing facilities, their scope of services and their criteria for care. Knowledgeable and experience in medical/legal aspects of care. Knowledge of Interqual Criteria a must.
Job: *Case Management
Title: Manager, Utilization Review
Location: South Carolina-Charleston-Trident Medical Center
Requisition ID: 00062-19671