Position Summary: Under the direction of the Senior Vice President of Clinical Services, the Director of Case Management provides strategic leadership and oversight for all aspects of Case Management, Complex Case Management, Transition of Care, and Population Health Management programs. The Director is responsible for the development, implementation, evaluation, and continuous improvement of care management programs to ensure alignment with organizational goals, regulatory requirements, industry best practices, and delegated health plan contractual obligations.

The Director has primary responsibility for the daily planning, coordination, monitoring, and oversight of Case Management operations, including staff leadership, mentoring, performance management, and audit readiness. This role ensures effective care coordination across the continuum of care, promotes smooth transitions between care settings, enhances the member experience, and improves clinical outcomes.

The Director oversees daily clinical operations to support the achievement of organizational, operational, and financial goals. Through collaboration with interdisciplinary teams and external stakeholders, the Director is accountable for reducing avoidable admissions (ADK), emergency department utilization (EDK), and readmissions across all contracted health plans.

The Director ensures all Case Management, Complex Case Management, Transition of Care, and Population Health Management activities are administered in accordance with NCQA standards, CMS requirements, state and federal regulations, and delegated health plan requirements. Responsibilities include oversight of program development, annual program evaluations, quality improvement initiatives, member engagement strategies, interdisciplinary care team functions, and ongoing accreditation and audit readiness activities.

Essential Position Functions/Responsibilities:
• Creates/maintains an environment that attracts strong talent, encourages high/engagement and low turnover, and promotes job satisfaction and retention
• Provides day-to-day oversight of Case Management clinical operations, ensuring all practices and programs are aligned with the overall strategic plan of the organization and follow best-practice standards.
• Sets direction for Case Management staff, ensuring accountability, quality outcomes, and follow-through.
• Analyses various Case Management reports to identify gaps and strengths that support operational deliverables while providing exceptional member care.
• Drive initiatives to reduce preventable admissions and readmissions across targeted lines of businesses.
• Facilitate and participate in committees, task forces, and multidisciplinary teams to promote standardized approaches to care management.
• Monitor all work products to ensure compliance with state and federal mandates and aligns with HCP's contractual obligations.
• Provides oversight of Complex Case Management (CCM), Transition of Care (TOC), and Population Health Management (PHM) programs to ensure compliance with NCQA accreditation standards.
• Ensures annual program descriptions, evaluations, work plans, policies, procedures, and interventions are developed, implemented, monitored, and updated in accordance with NCQA requirements.
• Oversees member identification, stratification, assessment, care planning, interdisciplinary care team activities, and member engagement activities consistent with NCQA standards.
• Leads preparation and response activities for NCQA surveys, health plan audits, delegated oversight reviews, and regulatory examinations.
• Maintains audit-ready documentation and evidence to support accreditation, delegation, and contractual requirements.
• Collaborates with Quality Management leadership to identify opportunities for performance improvement and implement corrective action plans when necessary.
• Utilizes data analytics to monitor program effectiveness, member outcomes, quality measures, utilization trends, and cost of care.
• Ensures annual evaluation of program effectiveness, including intervention outcomes, member satisfaction, and achievement of established goals.
• Oversees interdisciplinary care team activities involving nursing, social work, behavioral health, pharmacy, and provider partners to ensure comprehensive care coordination across the continuum.
• Ensures members receive individualized care plans addressing clinical, behavioral, psychosocial, and social determinants of health needs.
• Provides leadership and direction to direct reports.

Qualification Requirements:
Skills, Knowledge, Abilities
• Strong clinical expertise in care coordination, complex case management, and discharge planning.
• Excellent verbal and written communication skills with ability to convey complex clinical and operational concepts clearly.
• Demonstrated ability to lead interdisciplinary teams in a fast-paced, high-volume environment.
• Strong analytical, critical thinking, and problem-solving skills.
• Ability to perform comprehensive assessment of physical and psychosocial needs of patients.
• Proven ability to manage multiple priorities under tight deadlines.
• Experience with process improvement and performance optimization initiatives.
• Ability to build strong relationships and collaborate effectively across clinical and non-clinical stakeholders.
• Experience managing delegated health plan programs and participating in delegation audits.
• Knowledge of Medicare, Medicaid, Commercial, and Managed Care regulatory requirements.
• Thorough knowledge of NCQA Population Health Management (PHM), Complex Case Management (CCM), and Transition of Care standards.
• Understanding of utilization management, risk management, and compliance standards.
• Ability to develop and execute operational strategies aligned with organizational goals.

Training/Education:
• Graduate of an accredited nursing or health-related program required; Master's Degree preferred.
• Current RN license required; BSN preferred.
• CCM certification required.
• Strong clinical assessment skills, including physical and psychosocial evaluation of patients.
• Direct acute care clinical experience preferred.

Experience:
• 7+ years of progressive leadership experience in healthcare, managed care, or care coordination settings.
• 5+ years of experience in case management, discharge planning, or care transitions.
• 3-5+ years of experience in supervisory or line management roles overseeing clinical operations.
• Demonstrated experience leading care management or utilization management teams.
• Experience managing process improvement and care transition initiatives.
• Strong background in discharge planning, transitional care, and reduction of readmissions.
Base Compensation: $130,000 - $150,000 annually
Bonus Incentive: Eligibility based off organizational performance
Benefits: Fully paid Medical & Dental employee coverage + robust benefits package (PTO, 401k, FSA, Tuition Reimbursement, etc.)

Job Disclaimer:
The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.

Department: Clinical Services This is a management position This is a full time position