Director of Clinical Care Management

Clinical Program Leadership 

• Provide overall clinical operations leadership for CCM and PCM services. 

• Develop and implement standardized clinical care management workflows across participating markets and facilities. 

• Partner with physician leadership to establish clinical standards, escalation protocols, and care management expectations. 

• Ensure vendors and/or internal staff have regulatory guidance on appropriate identification and management of patients with chronic and complex medical conditions. 

•  Develop standardized comprehensive care plans addressing common chronic conditions, including heart failure, COPD, diabetes, chronic kidney disease, hypertension, dementia, and other high-risk conditions. 

• Establish appropriate clinical escalation pathways between care managers, facility nurses, APPs, physicians, specialists, and other members of the care team. 

• Ensure patients have appropriate access to clinical support and escalation consistent with applicable program requirements. 

• Promote proactive rather than reactive management of high-risk patients. 

 Care Management Team Leadership 

• Recruit, develop, and oversee RNs, LPNs, MAs, care coordinators, and other clinical care management personnel as appropriate. 

• Support staffing models and patient-to-care-manager ratios based on acuity, enrollment, productivity, and program requirements. 

• Develop performance expectations and productivity standards for the care management team. 

• Conduct regular individual and team performance reviews. 

• Provide clinical coaching, education, and competency development. 

• Establish standardized onboarding and training for new care management staff. 

• Monitor workload distribution and adjust staffing as program enrollment grows. 

 Patient Identification & Enrollment 

• Develop systematic processes to identify CCM- and PCM-eligible patients. 

• Partner with analytics, operations, and technology teams to automate patient identification wherever possible. 

• Establish processes to validate patient eligibility and active facility census. 

• Develop resident, patient, family, and MPOA education and communication processes. 

• Oversee consent and enrollment workflows. 

• Monitor the enrollment funnel from eligible patient through successful program activation. 

• Identify and address barriers contributing to unsuccessful enrollment. 

 Comprehensive Care Planning 

• Ensure each enrolled patient has an appropriate comprehensive, individualized care plan. 

• Establish standards for medication reconciliation, chronic disease management, functional status, psychosocial needs, goals of care, and specialist coordination. 

• Ensure care plans are reviewed and updated based on changes in patient condition and applicable program requirements. 

• Facilitate communication of relevant care-plan information with physicians, facilities, specialists, patients, families, and other members of the care team. 

• Promote continuity of care across transitions between SNF/LTC, hospital, home, and other settings. 

Facility & Provider Relationships 

• Develop strong working relationships with SNF and LTC Administrators, Directors of Nursing, nursing teams, social services, and other facility leadership. 

• Educate facility teams regarding the purpose and value of CCM and PCM. 

• Establish regular communication with participating facilities regarding patient needs, clinical concerns, and program performance. 

• Partner with physicians and APPs to ensure timely response to care management recommendations and identified changes in condition. 

• Participate in facility and provider meetings as appropriate. 

Compliance & Documentation 

• Maintain current knowledge of CMS requirements applicable to CCM and PCM services. 

• Ensure clinical workflows support applicable eligibility, consent, documentation, care planning, time tracking, supervision, and billing requirements. 

• Establish documentation standards and auditing processes. 

• Ensure qualifying clinical activities are accurately documented and appropriately attributed. 

• Partner with Compliance and Revenue Cycle to maintainappropriate separation between clinical care delivery and billing determination. 

• Conduct routine internal audits and implement corrective action when deficiencies are identified. 

• Monitor potential duplication or conflicts with other care management services. 

Revenue Cycle Partnership 

• Partner closely with Revenue Cycle Management to establish reliable CCM and PCM billing workflows. 

• Manage and direct pre-billing clinical documentation audits. 

• Validate that documentation supports services submitted for reimbursement. 

• Monitor claim acceptance, denial trends, collections, and documentation-related billing issues. 

• Work collaboratively with RCM to identify and correct recurring workflow or documentation problems. 

 Technology & Data 

• Partner with technology leadership to develop efficient care management documentation and workflow tools. 

• Establish workflows for accessing facility EMRs, including systems such as PointClickCare and MatrixCare where applicable. 

• Identify opportunities to automate eligibility identification, census reconciliation, patient assignment, clinical alerts, care-plan distribution, and reporting. 

• Participate in evaluation and implementation of technology supporting care management operations. 

• Provide insight and KPI metrics required for dashboards providing real-time visibility into program performance. 

 Quality & Outcomes 

• Establish and monitor clinical, operational, and financial KPIs, including: 

• Eligible patient population, Patient enrollment and consent rate, Active CCM/PCM enrollment 

• Patients per care manager, Care-plan completion, Monthly care management activity 

• Documentation compliance, Clinical escalation volume, Medication-related interventions 

• Avoidable ED utilization, Hospital admissions and readmissions, Facility and provider satisfaction 

• Claims submitted, Clean claim rate, Collections per enrolled patient, Cost per patient 

• Program contribution margin and Analyze trends and implement performance improvement initiatives when targets are not achieved. 

 Program Development & Growth 

• Support the development of standardized facility launch and education materials. 

• Identify opportunities to increase appropriate enrollment within existing populations. 

• Partner with leadership on expansion into additional care management programs and value-based initiatives. 

• Support integration of CCM/PCM with other clinical programs, includingTCM, RPM, post-discharge care management, and population health initiatives. 

• Participate in strategic discussions with health plans, ACOs, hospitals, physician groups, and post-acute partners when appropriate. 

1. Registered Nurse (RN) with active and unrestricted license.Bachelor's degree in nursing or related healthcare field.
2. Minimum5–7 years of progressive clinical leadership or care management experience.
3. Experience managing chronic and medically complex patient populations.
4. Demonstrated experience leading clinical teams.
5. Strong knowledge of care coordination, chronic disease management, medication reconciliation, and interdisciplinary care planning.
6. Experience developing standardized clinical workflows and performance metrics.
7. Strong analytical, organizational, communication, and leadership skills.
8. Ability to manage programs across multiple facilities, markets, and states. 

Physical Requirements: