Job Description
ABOUT SHERIDAN MEMORIAL HOSPITAL At Sheridan Memorial Hospital, we proudly rank in the top 13.6% of U.S. hospitals, recognized by the Centers for Medicare and Medicaid Services. With over 850 dedicated employees and 100+ expert providers across 25 specialties, we are committed to exceptional, patient-centered care. Set in northern Wyoming’s stunning Big Horn Mountain foothills, Sheridan offers outdoor adventure and community charm. Our hospital combines cutting-edge technology with a collaborative, innovative culture. Join a team that values your skills, fosters growth, and empowers you to impact lives meaningfully. Apply today and be part of Sheridan Memorial Hospital’s mission of excellence! JOB SUMMARY Responsible for the management and overall activities and functions of the Case Management and Utilization Review department. Department services include Care Coordination, Discharge Planning, Utilization Review, Denials Management and Case Management. Provides support/replacement when the Care Coordinator, Utilization Review Nurse or the Discharge planner are not available or are overtaxed and require assistance. Produces and manages agreed upon metrics and reports for distribution to other stakeholders per policy and procedure. Provides operational leadership to the Utilization Review Committee. Provides operational leadership of regulatory requirements for discharge planning, readmission reduction and reporting for quality metrics. Updates the Utilization Review plan for the organization as required. ESSENTIAL JOB FUNCTIONS Oversight of EHR (Executive Health Resources) referrals and usage. Responsibility for the following functions: Utilization Review Care Coordination Discharge Planning Denials Management Access Case Management Management of qualifications, competencies, staffing levels, workload and productivity, regulatory compliance, continuing education, performance evaluations, and onboarding process within the department Builds program collaboration with physician in areas of discharge planning and utilization review to allow continuous improvement in practices and ongoing education with medical necessity standards. Maintenance of systems, processes and education to improve customer satisfaction and SMH outcomes Expertise in application of CMS Conditions of Participations and other regulations and standards for the Joint Commission and consistently updates the Department accordingly Review Medical Management data for trends and opportunities for improvement Review current processes regularly to ensure maximum efficiency and effectiveness, including but are not limited to: Length of stay Long-stay patients Readmissions Denials Medicare Beneficiary Notice Compliance Condition Code 44 compliance Patient choice compliance Avoidable day compliance Shows initiative by suggesting improvements using innovative and creative problem-solving abilities. Provides coaching and mentoring to others to achieve department goals. Re-evaluates department data and assesses the success of department plans, constantly makes suggestions and revises the department's goals and plans as necessary to adjust to changing healthcare rules and regulations. Displays role-modeling behavior. Exhibits clear, open and honest communication with others. Establishes and maintains effective relationships with department heads, nursing managers and administrators and administrative staff Oversee the development and compliance with departmental policies and procedures. Review all readmissions per conditions of participation, collaborating with physicians as appropriate in the review. Actively participates in the UM Committee, leading the presentation of data and metrics including but not limited to: Utilization Readmissions Quality LOS Opportunities for improvement. Outlier case review per the utilization management plan. Collaboration in the development of the utilization management annual plan. Analyzes and presents departmental metrics explaining all variances and presenting opportunities for improvement. Provides data for quality council and other requests to measure ongoing performance in meeting departmental and organizational metrics. Leadership and Human Resource Management Demonstrates consistent leadership perfo