Director of Integrated Care Mgmt

Summary

The Director of Integrated Care Management provides strategic, operational, and clinical leadership for the Integrated Care Management Department, ensuring the delivery of coordinated, patient-centered, high-quality, and fiscally responsible care across the continuum.

This position has strategic and operational oversight for Utilization Review, RN and Social Work Case Management, Clinical Social Work Services, the Readmission Prevention Program, Congestive Heart Failure (CHF) Navigation, the HOPE Program, and other care management initiatives that support safe transitions of care, effective resource utilization, and optimal patient outcomes.

The Director is responsible for departmental strategy, financial stewardship, regulatory compliance, accreditation readiness, quality improvement, and operational performance while ensuring compliance with applicable federal and state regulations, including CMS Conditions of Participation, and accreditation standards established by the hospital's accrediting organization.

In collaboration with physicians, nursing, revenue cycle, quality, finance, and operational leaders, the Director advances organizational priorities related to care progression, utilization management, patient flow, readmission reduction, patient experience, and equitable access to care across the continuum.

Essential Duties and Responsibilities

The following statements describe the general nature and level of work performed by the Director of Integrated Care Management.

Leadership and Strategic Oversight

• Provides strategic, operational, and clinical leadership for the Integrated Care Management Department, including Utilization Review nursing, RN and Social Work Case Management, Clinical Social Work Services, Readmission Prevention, Congestive Heart Failure (CHF) Navigation, the HOPE Program, and future care management initiatives, ensuring achievement of program objectives, regulatory requirements, grant obligations, and organizational priorities.

• Establishes departmental vision, strategic priorities, goals, performance metrics, and regulatory strategies aligned with organizational objectives.

• Leads the development, implementation, and evaluation of strategic initiatives that improve patient outcomes, care delivery, operational efficiency, regulatory compliance, care progression, and organizational performance across the continuum of care.

• Provides leadership through managers and direct reports, fostering a culture of accountability, collaboration, innovation, professional development, continuous improvement, and evidence-based practice.

• Directs departmental operations to promote safe, efficient, patient-centered care coordination, utilization management, care progression, discharge planning, transitions of care, and optimal resource utilization across the continuum.

Regulatory, Accreditation, and Quality

• Ensures departmental compliance with applicable federal and state regulations, CMS Conditions of Participation, payer requirements, patient rights, and accreditation standards established by the hospital's accrediting organization.

• Develops, implements, and evaluates departmental policies, procedures, documentation standards, competencies, workflows, and evidence-based practices to support regulatory compliance, operational excellence, accreditation readiness, and continuous quality improvement.

• Leads performance improvement initiatives that enhance care progression, resource utilization, regulatory compliance, patient outcomes, and key operational metrics, including length of stay, avoidable days, medically ready patients, readmission reduction, and transitions of care.

Care Coordination and Utilization Management

• Provides strategic oversight of interdisciplinary care management services to promote patient-centered care coordination, discharge planning, behavioral health and psychosocial intervention, community resource management, patient advocacy, equitable access to care, and safe transitions across the continuum.

• Provides operational oversight of the Utilization Review nursing team, ensuring timely medical necessity review, patient status determination, regulatory compliance, appropriate reimbursement, and effective collaboration with Physician Advisors, Revenue Cycle, and clinical leadership to optimize resource utilization.

Financial and Operational Management

• Develops, administers, and monitors departmental operating and personnel budgets; oversees productivity, workforce planning, and resource utilization; and provides leadership for staffing, contractual agreements, capital requests, and operational improvements consistent with organizational policies.

• Monitors departmental performance through key quality, operational, financial, and regulatory metrics, utilize data to identify opportunities, evaluate outcomes, and implement sustainable process improvements.

• Collaborates with executive leadership, finance, quality, performance analytics, revenue cycle, and operational leaders to advance organizational priorities related to patient flow, throughput, capacity management, and healthcare value.

Collaboration and Professional Leadership

• Builds and maintains collaborative relationships with physicians, nursing, ancillary departments, post-acute providers, community agencies, and executive leadership to improve care coordination, care progression, patient outcomes, and continuity of care.

• Provides administrative oversight of multidisciplinary discharge planning and length-of-stay initiatives, facilitating interdisciplinary collaboration and barrier resolution to optimize patient flow and transitions of care.

• Represents the department on organizational committees, interdisciplinary work groups, ethics committees, and community partnerships, providing leadership and subject matter expertise in integrated care management, clinical utilization management, regulatory compliance, and care transitions.

• Collaborates with legal counsel, finance, revenue cycle, compliance, quality, risk management, and community partners to develop and implement strategic initiatives, innovative programs, contractual agreements, and operational solutions that improve patient access, support organizational objectives, and optimize resource utilization.

Supervisory Responsibilities

Reports to: Chief Clinical Officer

Supervises: Provides direct and indirect leadership for the Integrated Care Management Department, including Utilization Review nursing, RN and SW Case Managers, Social Work Services, Readmission Prevention, Disease-Specific Navigation, the HOPE Program, and any other implemented care management programs.

Responsibilities: Responsible for departmental strategy, operations, financial stewardship, regulatory compliance, quality improvement, workforce development, and achievement of organizational goals across the continuum of care.

Qualifications

To perform this job successfully, an individual must be able to competently carry out each essential duty. The qualifications below represent the knowledge, skills, and abilities required.

Education and Experience

• Master’s degree in nursing, Business Administration, Healthcare Administration, or a related healthcare field required, or agreement to obtain within three (3) years of hire.

• Minimum of five (5) years of progressively responsible experience in acute healthcare, including care management, utilization management, care coordination, or related clinical or healthcare operations required.

• Minimum of two (2) years of progressive leadership experience within an acute care Case Management, Utilization Management, or Integrated Care Management department required.

Licenses and Certifications

• Active Registered Nurse (RN) license in the Commonwealth of Virginia required.

• Certification as an Accredited Case Manager (ACM) or Certified Case Manager (CCM) required.