Care Management Manager

Job Title: Care Management Manager

Location: Johnson County Hospital, Tecumseh, NE

Department: Nursing

Reports To: CNO

Position Summary:

The Care Management Manager is responsible for the operational and clinical oversight of the hospital's Care Management program, including Utilization Review (UR), care coordination, discharge planning, and payer medical necessity compliance. This role ensures compliance with CMS Conditions of Participation, supports appropriate patient status determination, collaborates with medical staff, and partners with Revenue Cycle and Patient Access to reduce denials and support efficient patient throughput.

This position provides leadership to care management staff and serves as a key liaison between clinical services, medical staff, quality, compliance, and revenue cycle operations.

Duties & Responsibilities:

Utilization Review & Medical Necessity

• Oversees the hospital's Utilization Review program in compliance with CMS Conditions of Participation, Medicare regulations, and payer requirements.
• Ensures timely and accurate medical necessity reviews.
• Monitors patient status determination (inpatient vs. outpatient/observation) and facilitates appropriate escalation to providers.
• Coordinates and prepares cases for Utilization Review Committee meetings; tracks outcomes and follow-up actions.
• Ensures physician advisor involvement when indicated.

Care Coordination & Discharge Planning

• Oversees care coordination and discharge planning processes to support safe, timely, and appropriate transitions of care.
• Collaborates with nursing, providers, therapy services, and ancillary departments to remove barriers to discharge.
• Ensures compliance with discharge planning regulations, including patient choice and post-acute care referrals.

Prior Authorization & Payer Coordination

• Collaborates with billing and revenue cycle to support timely prior authorization and concurrent review processes.
• Assists with clinical documentation and medical necessity appeals when required.
• Participates in payer communications related to medical necessity, level of care, and length-of-stay reviews.

Denials Prevention & Performance Improvement

• Analyzes utilization trends, denials data, and length-of-stay metrics to identify opportunities for improvement.
• Partners with other departments as necessary to reduce avoidable denials related to medical necessity or documentation.
• Develops and implements action plans to address identified gaps.

Compliance, Quality & QAPI Integration

• Ensures Care Management activities align with CMS Conditions of Participation, accreditation standards, and hospital policies.
• Participates in Quality Assurance and Performance Improvement (QAPI) initiatives related to utilization, throughput, and care coordination.
• Assists with survey readiness, mock surveys, and regulatory audits.

Leadership & Staff Management

• Provides direct supervision, coaching, and performance management of Care Management staff.
• Ensures staff competency through orientation, ongoing education, and annual evaluations.
• Develops and maintains department policies, procedures, and workflows.

Education & Provider Engagement

• Educates providers and staff on medical necessity requirements, documentation standards, and patient status guidelines.
• Promotes a collaborative approach to utilization management and care coordination.

Qualifications & Skills:

Required Qualifications

• Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice
• Experience in Utilization Review, Case Management, or Care Coordination
• Knowledge of CMS Conditions of Participation and Medicare regulations

Preferred Qualifications

• Certification in Case Management or Utilization Review (CCM, ACM, CPUR, or equivalent)
• Experience in a Critical Access Hospital or rural healthcare setting

Skills and Competencies

• Strong understanding of medical necessity and level-of-care determination
• Ability to interpret payer regulations and apply them to clinical scenarios
• Excellent communication and collaboration skills
• Leadership, coaching, and problem-solving abilities
• Strong organizational and analytical skills
• Ability to work independently and manage competing priorities

Working Conditions

• Primarily office-based with regular interaction in clinical areas
• May require on-call availability
• Must be able to maintain confidentiality and comply with HIPAA regulations

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not an exhaustive list of all responsibilities, duties, or qualifications required for the position.

Benefits We Offer:

• Competitive wages
• Comprehensive health, dental, and vision insurance
• Retirement savings plan
• Professional development opportunities
• Supportive and collaborative work environment
• Paid time off
• Sick pay

Why Join Us?

At Johnson County Hospital, we value our team and foster a supportive environment where you can thrive. Join us to make a difference in the lives of our patients and their families.