Director Case Management

Director Case Management
Location: Detroit, MI
Job Type: Full-Time
Work Model: Onsite
The 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 Environment

• Hospital-based leadership role within a Level I Trauma Center
• Fast-paced acute care environment
• Collaboration with physicians, nursing leadership, finance, revenue cycle, ancillary teams, and executive leadership
• Oversight of utilization management, transition planning, compliance, and care coordination
• Data-driven operational improvement environment

Key Responsibilities
Department Operations & Leadership

• Lead and oversee daily operations of the Case Management Department
• Ensure effective patient throughput and reimbursement optimization
• Maintain adequate staffing and skill mix across 7-day operations
• Conduct staff competency evaluations and performance reviews
• Lead departmental meetings, education sessions, and operational initiatives

Utilization Management

• Implement and oversee the hospital Utilization Management Plan
• Ensure accurate and timely medical necessity reviews in compliance with CMS and organizational policies
• Monitor payer communications, authorizations, denials, and peer-to-peer review processes
• Analyze Avoidable Days and utilization trends to drive performance improvement
• Participate in Revenue Cycle and Medicare Performance Improvement initiatives

Transition Management & Care Coordination

• Ensure timely transition planning assessments within 24 hours of admission
• Monitor patient placement and discharge planning workflows
• Support efficient sequencing of consults, procedures, and care delivery
• Lead Complex Case Review and Patient Care Conference processes
• Collaborate with interdisciplinary teams to optimize patient outcomes and throughput

Compliance & Regulatory Oversight

• Ensure compliance with:
  • CMS Conditions of Participation
  • TJC Accreditation Standards
  • Federal and state regulations
  • Organizational policies
• Implement and monitor compliance with Tenet Case Management practices
• Support internal and external audit readiness activities

Education & Physician Engagement

• Provide physician education regarding:
  • Medical necessity
  • Documentation accuracy
  • Regulatory compliance
  • Utilization performance
• Educate case management staff and healthcare teams on progression of care and transition planning best practices

Must-Have Qualifications

• Bachelor's Degree in:
  • Nursing
  • Healthcare-related field
    OR
  • Master's Degree in Social Work (MSW)
• Active RN or LCSW/LMSW license
• Minimum 3–5 years of acute hospital case management leadership experience
• Strong experience with:
  • Utilization Management
  • Transition Management
  • Care Coordination
  • Denial Prevention
  • Patient Throughput
  • Revenue Cycle collaboration
• Strong understanding of:
  • CMS Regulations
  • TJC Standards
  • Case Management compliance
• Strong leadership, operational, and communication skills

Preferred Qualifications

• Master's Degree in:
  • Nursing
  • Business Administration
  • Hospital Administration
• Accredited Case Manager (ACM) certification
• McKesson InterQual® experience
• Business planning experience
• Experience within Level I Trauma or large acute care hospital environments

Core Skills

• Hospital Case Management
• Utilization Management
• Transition Management
• Care Coordination
• Denial Prevention
• Patient Throughput Optimization
• Revenue Cycle Collaboration
• CMS & TJC Compliance
• InterQual Reviews
• Physician Education
• Acute Care Operations
• Team Leadership & Staff Development