Director Case Management

About the Job The Director of Case Management provides strategic and operational leadership for the health plan's enterprise case management function across two health plans under a centralized clinical operations model. The Director oversees case management activities that may include behavioral health, utilization management, and care management functions, and serves as a liaison to government and other regulatory agencies. 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 (e.g., transportation and personal care services), behavioral health case management, and special population services (e.g., unhoused enrollees and pediatric case management). Establishes and maintains a monitored reporting cadence for enrollees in case management that includes annual assessments, critical incidents, special populations, behavioral health, and transitions of care coordination efforts. Provides 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; ensures 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 readmissions through proactive care coordination. Monitors medical expense impact and total cost of care trends related to care management interventions. Establishes and monitors 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 managers 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, establishing reasonable expectancy targets for the assigned work. Drives continuous process improvement initiatives using data analytics and performance insights. Partners with finance and actuarial teams 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. Education Nursing, Social Work, or related healthcare field accredited School of Nursing required. Nursing (MSN), Public Health (MPH), Healthcare Administration (MHA), Business Administration (MBA), or related field preferred. Experience 8–10 years progressive experience in managed care or health plan operations required. 5–7 years leadership experience in case management, care coordination, or population health management required. Experience leading multi‑market or centralized teams preferred. Proven track record of improving quality outcomes, reducing avoidable utilization, and managing medical expense trends. Experience with regulatory audits (state Medicaid agencies, CMS) and NCQA accreditation processes. Experience implementing risk stratification tools and data‑driven care models. Prior experience collaborating with utilization management, pharmacy, quality, and provider relations functions. Key Skills and Abilities Strong knowledge of state Medicaid,```json { #J-18808-Ljbffr