The Director will direct and manage departmental activities involved in utilization review, appeals management and discharge planning to facilitate the case management process and maximize reimbursement to the hospital. Must be able to navigate through a wide variety of managed care contractual issues. Must have knowledge of and familiarity with Interqual and Millman criteria. The position also oversees Social Work Department responsible for discharge planning.

Responsibilities

1.Reviews department clinical services and operations, and tracks case management activity. Identifies areas for performance improvement by examining productivity and workload within each department. Directs, coaches, mentors and assesses staff in clinical case management service delivery.

2.Ensures departments achieve institutional visions, goals and objectives by developing scope of service, establishing/maintaining effective relationships with physicians, and collaborating with other disciplines. Assesses goals and utilizes data to effect corrective action.

3.Oversees activities of onsite Case Managers.

4.Presents regular productivity reports, and meets with Case Management staff on an individual basis to discuss targets and other issues of concern.

5.Attends Joint Conference meetings with major payers.

6.Develops relationships and seeks feedback from internal and external stakeholders regarding the implementation of department activities to garner satisfactory customer results.

7.Emphasizes a collaborative approach and seeks to influence other services by focusing on patient processes.

8.Develops and implements Utilization Review (UR) based on internal data collection, data received from external agencies, Physician

9.Advisors and the Medical Director.

10.Ensures Discharge Appeals functions are carried out within contractual, federal and state guidelines. Presents and reviews data relative to avoidable days, denials, length of stay and other key metrics to leadership.

Qualifications

Education Requirements

Bachelor of Science with a major in nursing

Master’s degree in nursing or healthcare-related field

Experience Requirements

5 years of Case Management and 6 years of clinical nurse experience.

Previous supervisory experience in Case Management or a related field.

Licensing and Certification Requirements (if applicable)

Licensed as a registered nurse, Issuing Agency: Department of Health/Office of Professions in the state of New York.

Professional Board Certification in leadership and/or clinical specialty is preferred.

Basic Life Support (BLS) Issuing Agency: AHA

Advanced Cardiovascular Life Support (ACLS) Issuing Agency: AHA (in ED; PACU/ASU; ICUs; Telemetry Units; SDU; IR, Interventional Cardiology (CCL/EP/Echo); L&D; Endoscopy, and APN Adult Oncology

Certification: NRP (Labor and Delivery, NICU dept)

Pediatric Advanced life Support (PALS) Issuing Agency: AHA (in ED; PACU; IR; Peds ICU, and APNs Pediatric Oncology depts.)

Compensation Statement

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $127,044.00 – $190,565.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Non-Bargaining Unit, 140 – Care Management – MSQ, Mount Sinai Queens

Employer Description

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report’s Best Hospitals, receiving high “Honor Roll” status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children’s Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $127044 – $190565 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.