Regional Director of Case Management

General Purpose

The Regional Director of Case Management provides strategic and operational leadership for the case management and utilization review functions across all regional skilled nursing facilities. This role focuses on optimizing resident transitions of care, maximizing reimbursement accuracy under the Patient-Driven Payment Model (PDPM) and Managed Care contracts, managing Length of Stay (LOS), and reducing acute care readmissions.

The ideal candidate will bridge the gap between clinical excellence and financial sustainability, ensuring high-quality patient care while safeguarding the organization's financial health.

Essential Duties

• Oversee the managed care authorization process across the region. Ensure timely initial certifications, concurrent reviews, and appeals to minimize insurance denials and peer-to-peer reviews.
  Partner with Regional MDS Minimum Data Set) Directors and Therapy Directors to ensure clinical locumentation accurately reflects patient acuity, capturing appropriate PDPM mapping and revenue.
• Drive regional strategies to achieve optimal LOS. Ensure facility case managers are actively planning safe, sustainable discharges back home or to lower levels of care to prevent avoidable days.
• Analyze regional hospital readmission data. Implement protocols to identify "at-risk" residents early and collaborate with clinical teams to manage acute changes in condition in place.
• Serve as the primary regional liaison for hospital discharge planners, Accountable Care Organizations (ACOs), and Managed Care Organizations (MCOs) to drive preferred-provider status and census growth.
• Ensure all case management activities comply with CMS guidelines, State Departments of Health, and Office of Inspector General (OIG) regulations.

Supervisory Requirements

This role may include direct and/or indirect supervisory responsibilities, as assigned by manager.

Qualification

Education and/or Experience

• Bachelor's degree in Nursing (BSN) or Master's degree in Social Work (MSW), Healthcare Administration, or a related field required
• Minımum of 5 years of case management experience in a skilled Nursing (SNF) or Post-Acute environment, with a least 2-3 years in a regional or multi-site supervisory role.
• Deep understanding of PDPM, Medicare Part A & B, Medicaid, Managed Care contracts, and Triple Check processes.
• Active, unrestricted RN, LPN/L VN, or LCSW/LIS W license in the state (s) of operations.
• RAC-CT (Resident Assessment Coordinator) or CCM (Certified Case Manager) is highly desirable.
• Deep understanding of PDPM, Medicare Part A & B, Medicaid, Managed Care contracts, and Triple Check processes.

Physical Demands

• Sitting at a desk and computer use (up to 8 hours/day). Occasional lifting and carrying of files or laptop bags up to 20lbs.
• Frequent standing and walking during facility audits and site visits. Regular regional travel (driving or flying) with extended periods of transit.
• Sufficient vision to read clinical charts and spreadsheets; sufficient hearing for effective phone, video, and in-person communication.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually low to moderate.

Additional Information

Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above.

They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.

Pay Range: $165,000- $175,000

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.