Director Case Management - Relocation Offered!

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.

• 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

• 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

• 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

• 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.