Director Case Management

About the Job

General Summary of Position

The Director of Case Management provides strategic and operational leadership for the health plan's enterprise case management function across two health plans under a centralized clinical operations model. The Director of Case Management (DCM) is responsible for the operational functions the Case Management team including the direct supervision coaching and counseling of staff. The DCM will direct and coordinate the Case Management operations staff with specific focus on Person Centered Enrollee Care and the Enrollee Continuum of Care models. This role designs standardizes implements and optimizes care management programs to improve quality outcomes enhance enrollee experiences reduce avoidable utilization and ensure regulatory compliance. The Director of Case Management (DCM) oversees case management activities that may include behavioral health utilization management and care management functions and serves as a liaison to government and other regulatory agencies as well as internal departments. The Director monitors staff and program performance compares results against goals recommends improvements and decisions aligning with expected outcomes. The Director supports Managers managing case management coordination and care management staff. The Director ensures adherence of case management programs across markets while addressing unique state-specific regulatory and population needs partners closely with Utilization Management Pharmacy Quality Population Health Equity and Provider Relations to drive enterprise clinical performance.

Primary Duties and Responsibilities

Leads the enterprise case management strategy across both health plans ensuring alignment with clinical quality and financial goals.Develops and manages the field-based activities of the Case Management Assessment Team (CMAT) of RN Field Case Managers to ensure person-centered enrollee care and strict contractual compliance.Oversees and ensures the timely execution of Case Management activities related to Enrollee Discharge Planning Transitions of Care special benefit operations (for example transportation and personal care services) Behavioral Health Case Management and Special Population Services (for example unhoused enrollees and pediatric case management).Establishes and maintains a monitored reporting cadence (for example reports and dashboards) for enrollees in case management that include annual assessments critical incidents special populations behavioral health and transitions of care coordination efforts.Ensures dashboard oversight for the production and validation of case management activities including standardized goals and scorecards to support contractual compliance and both individual and health plan case management performance.Standardizes case management policies workflows and documentation practices across markets while maintaining state-specific regulatory compliance.Monitors and improves member engagement rates including outreach success care plan completion and sustained participation. Ensure seamless integration between Case Management and Utilization Management to reduce fragmentation and duplication of effort.Partners with Pharmacy leadership to coordinate care for members utilizing high-cost or specialty medications.Collaborates with Quality Improvement teams to close gaps in care and improve HEDIS and other performance metrics.Develops strategies to reduce avoidable emergency department visits and hospital readmission through proactive care coordination.Monitors medical expense impact and total cost of care trends related to care management interventions.Establishes and monitor key performance indicators (KPIs) including engagement rates readmission rates care plan timeliness and staff productivity while driving measurable outcomes.Ensures compliance with state Medicaid agencies CMS NCQA and contractual requirements across both health plans deploying corrective action plans where applicable.Supervises and develops manager and supervisors ensuring strong leadership cascade and accountability within a centralized structure.Designs and optimizes centralized staffing models and caseload distribution to ensure efficiency and effectiveness. Establish RE's/Reasonable Expectancy targets for the assigned work.Drives continuous process improvement initiatives using data analytics and performance insights.Partners with Finance and Actuarial team to evaluate the ROI of care management programs.Supports value-based payment and alternative payment models aligning case management strategies with provider performance incentives.Provides executive-level reporting and strategic recommendations to the VP of Clinical Operations and senior leadership.Champions a culture of member-centered culturally competent care coordination that improves health equity and outcomes across both markets. Minimal Qualifications

Education

• Bachelor's degree Nursing Social Work or related healthcare field required and
• Master's degree Nursing (MSN) Public Health (MPH) Healthcare Administration (MHA) Business Administration (MBA) or related field preferred

Experience

• 8-10 years Progressive experience in managed care or health plan operations. required and
• 5-7 years Leadership experience in case management care coordination or population health management. required and
• Demonstrated experience overseeing complex case management programs in Medicaid managed care strongly preferred. required and
• Experience leading multi-market or centralized teams preferred. required and
• Proven track record of improving quality outcomes reducing avoidable utilization and managing medical expense trends. required and
• Experience with regulatory audits (state Medicaid agencies CMS) and NCQA accreditation processes. required and
• Experience implementing risk stratification tools and data-driven care models. required and
• Prior experience collaborating with Utilization Management Pharmacy Quality and Provider Relations functions. required

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Active unrestricted clinical license; Multi-state licensure or eligibility for licensure in Maryland and DC.(RN strongly preferred) Upon Hire required or
• LCSW- License Clinical Social Worker Multi-state licensure or eligibility for licensure in Maryland and DC Upon Hire required or
• other licensed clinicians may be considered Upon Hire required and
• CCM - Certified Case Manager Certified Case Manager (CCM) or other nationally recognized case management certification Upon Hire required

Knowledge Skills and Abilities

• Strong knowledge of state Medicaid CMS NCQA and contractual requirements related to case management and care coordination.
• Deep understanding of population health management social determinants of health and risk-based care models.
• Financial acumen with the ability to interpret PMPM trends total cost of care data and ROI analysis.
• Expertise in care transitions complex case management maternal health behavioral health integration and high-risk population management.
• Ability to lead organization change within a centralized clinical operations model.
• Strong analytical skills with the ability to translate data into actionable strategy.
• Excellent executive-level communication and presentation skills.
• Proven ability to build high-performing teams and drive accountability.
• Skilled in cross-functional collaboration and stakeholder engagement.
• Demonstrated commitment to culturally competent member-centered care.
• Proficiency with care management platforms electronic health records and reporting tools.

This position has a hiring range of

USD $120,702.00 - USD $238,222.00 /Yr.