Position Summary: The Case Management Department Leader provides comprehensive operational oversight for hospital utilization management, transition management, and department workflows. This role ensures the efficient allocation of hospital resources, supports accurate revenue cycle processes, drives denial prevention, and promotes safe, timely patient throughput while maintaining strict compliance with state, federal, TJC, and organizational standards. Core Scope of Services:
Utilization Management: Evaluates medical necessity and actively drives denial prevention strategies.
Transition Management: Optimizes length of stay, prevents readmissions, and enhances patient satisfaction.
Care Coordination: Ensures throughput efficiency, correct care sequencing, and appropriate care levels.
Regulatory Compliance: Adheres to state and federal mandates, TJC accreditation standards, and organizational policies.
Stakeholder Education: Provides guidance to physicians, patients, families, and caregivers.
Key Responsibilities:
Operations & Reimbursement: Direct department operations to secure effective patient throughput and optimize service reimbursement.
Utilization Performance: Lead the implementation and oversight of the hospital Utilization Management Plan, leveraging data analytics to drive continuous performance improvement.
Revenue Cycle Integrity: Ensure medical necessity and revenue cycle workflows are executed with precision, fully complying with CMS regulations and internal policies.
Transition & Throughput: Facilitate timely, effective patient transitions and discharge planning to support seamless hospital throughput.
Physician Engagement: Develop and deliver targeted education and performance feedback regarding hospital utilization practices.
Additional Duties: Perform other related duties as assigned.
Required Qualifications:
Education: Bachelor's degree in Business, Nursing, or Health Care Administration (for RN candidates); or a Master's degree in Social Work (for MSW candidates).
Experience: Minimum of 3 years of acute hospital case management or healthcare leadership experience.
Licensure & Certification: Active Registered Nurse (RN) or LCSW/LMSW license, maintaining current certification or registration to practice as required by state law and organizational policy.
Preferred Qualifications:
Education: Advanced degree, including MSN, MBA, MSW, or MHA.
Experience: 5 years of acute hospital case management leadership experience within multi-site operations.
Licensure & Certification: Accredited Case Manager (ACM) credential.
Numbers & Facts
Location
Massachusetts, MA
Salary
$120,000–$193,000 Per Year
Skills
Academic Adviceunmatched
Accreditation Standardsunmatched
Acute Careunmatched
Business Administrationunmatched
Case Managementunmatched
Certified Case Manager (CCM)unmatched
Content Management Systems (CMS)unmatched
Correctional Healthunmatched
Data Analysisunmatched
Discharge Plansunmatched
Healthcareunmatched
Healthcare Administrationunmatched
Hospitalunmatched
Hospital Administrationunmatched
Leadershipunmatched
Licensed Clinical Social Worker (LCSW)unmatched
Maintain Complianceunmatched
Nursingunmatched
Patient Care Denialsunmatched
People Managementunmatched
Performance Managementunmatched
Process Improvementunmatched
Registered Nurse (RN)unmatched
Regulationsunmatched
Regulatory Complianceunmatched
Reimbursementunmatched
Resource Managementunmatched
Social Workunmatched
State Laws and Regulationsunmatched
Time Managementunmatched
Training/Teachingunmatched
Utilization Managementunmatched
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