Director of Case Management

Key Responsibilities

Leadership & Strategy

Develop and implement the strategic vision for the Case Management department in alignment with organizational objectives and financial targets.
Lead, mentor, and manage a team of case managers, social workers, and support staff; oversee hiring, training, performance evaluations, and professional development.
Collaborate with the CFO and executive leadership to optimize resource utilization, reduce length of stay, and minimize avoidable readmissions.
 

Clinical & Operational Oversight

Oversee all aspects of case management including admission and continued stay reviews, discharge planning, and transitions of care.
Ensure timely and appropriate level-of-care determinations in accordance with medical necessity criteria (InterQual, Milliman Care Guidelines, or equivalent).
Monitor departmental metrics, key performance indicators (KPIs), and outcomes; prepare and present reports to senior leadership.
Implement process improvements to enhance patient flow, care coordination, and interdisciplinary collaboration.
 

Compliance & Quality

Ensure full compliance with federal, state, and accreditation standards including CMS Conditions of Participation, The Joint Commission, and state-specific case management regulations.
Maintain adherence to HIPAA privacy and security regulations.
Lead quality improvement initiatives and participate in accreditation surveys and audits.
Manage payer relationships and appeals processes related to denials and medical necessity disputes.
 

Financial Stewardship

Partner with the CFO and Revenue Cycle team to minimize revenue leakage, reduce denial rates, and support accurate documentation for reimbursement.
Analyze financial and operational data to identify trends, cost-saving opportunities, and areas for efficiency gains.
Oversee the department budget and resource allocation.