The Director of Case Management is primarily responsible for the administrative supervision of the Case Management Department.  Performs quality improvement measures and processes in collaboration with the Case Management Department and Utilization Review Committee.  Interprets medical information used in the processing of payments and claims.  Investigates denials by third party payers and crafts thorough appeals to justify medical necessity.  Also ensures that appeals are managed within required timeframes for maximum reimbursement.  Provides direct supervision of all appeals staff, overseeing the research, evaluation and response for complex cases.  

Compiles reports.  Prepares and assigns record review for Medical Staff Committees.  Assists in determining data formatting and types of indicators and studies.  Completes studies from beginning to end.  Maintains tracking of incomplete Utilization Review chart reviews, and performs other activities, as necessary. 

1. Graduate from an accredited school of nursing; baccalaureate degree required; masters degree preferred. 
2. Currently licensed as a professional nurse in the State of California. 
3. Possesses both good oral and written communication skills. 
4. Demonstrated interpersonal relationships in a manner which enhances communication, promotes conflict resolution and facilitates staff development. 
5. Requires knowledge or understanding or integration or software and hardware.  Demonstrates a willingness to learn new programs and obtain further education regarding computerization.
6. Basic Life Support certification required.
7. Must be knowledgeable in ICD-9-CM Coding.