Director Case Management

Director Case ManagementLocation: Detroit, MIJob Type: Full-TimeWork Model: OnsiteThe Director Case Management is responsible for overseeing utilization management, transition management, care coordination, compliance, and operational leadership of the hospital's Case Management Department.This leadership role drives hospital utilization performance improvement, denial prevention, patient throughput efficiency, regulatory compliance, and reimbursement optimization. The ideal candidate will possess strong acute hospital case management leadership experience with expertise in utilization review, payer management, care coordination, and interdisciplinary collaboration.Work EnvironmentHospital-based leadership role within a Level I Trauma CenterFast-paced acute care environmentCollaboration with physicians, nursing leadership, finance, revenue cycle, ancillary teams, and executive leadershipOversight of utilization management, transition planning, compliance, and care coordinationData-driven operational improvement environmentKey ResponsibilitiesDepartment Operations & LeadershipLead and oversee daily operations of the Case Management DepartmentEnsure effective patient throughput and reimbursement optimizationMaintain adequate staffing and skill mix across 7-day operationsConduct staff competency evaluations and performance reviewsLead departmental meetings, education sessions, and operational initiativesUtilization ManagementImplement and oversee the hospital Utilization Management PlanEnsure accurate and timely medical necessity reviews in compliance with CMS and organizational policiesMonitor payer communications, authorizations, denials, and peer-to-peer review processesAnalyze Avoidable Days and utilization trends to drive performance improvementParticipate in Revenue Cycle and Medicare Performance Improvement initiativesTransition Management & Care CoordinationEnsure timely transition planning assessments within 24 hours of admissionMonitor patient placement and discharge planning workflowsSupport efficient sequencing of consults, procedures, and care deliveryLead Complex Case Review and Patient Care Conference processesCollaborate with interdisciplinary teams to optimize patient outcomes and throughputCompliance & Regulatory OversightEnsure compliance with:CMS Conditions of ParticipationTJC Accreditation StandardsFederal and state regulationsOrganizational policiesImplement and monitor compliance with Tenet Case Management practicesSupport internal and external audit readiness activitiesEducation & Physician EngagementProvide physician education regarding:Medical necessityDocumentation accuracyRegulatory complianceUtilization performanceEducate case management staff and healthcare teams on progression of care and transition planning best practicesMust-Have QualificationsBachelor's Degree in:NursingHealthcare-related fieldORMaster's Degree in Social Work (MSW)Active RN or LCSW/LMSW licenseMinimum 3–5 years of acute hospital case management leadership experienceStrong experience with:Utilization ManagementTransition ManagementCare CoordinationDenial PreventionPatient ThroughputRevenue Cycle collaborationStrong understanding of:CMS RegulationsTJC StandardsCase Management complianceStrong leadership, operational, and communication skillsPreferred QualificationsMaster's Degree in:NursingBusiness AdministrationHospital AdministrationAccredited Case Manager (ACM) certificationMcKesson InterQual experienceBusiness planning experienceExperience within Level I Trauma or large acute care hospital environmentsCore SkillsHospital Case ManagementUtilization ManagementTransition ManagementCare CoordinationDenial PreventionPatient Throughput OptimizationRevenue Cycle CollaborationCMS & TJC ComplianceInterQual ReviewsPhysician EducationAcute Care OperationsTeam Leadership & Staff Development