Director of Case Management - Care Management

Tower Health•West Reading, PA

About The Position

The Director of Case Management is a critical leadership role that provides strategic leadership for utilization management, transition planning, and patient throughput. This role drives operational efficiency and regulatory compliance (CMS) while collaborating with executive leadership and physician advisors to meet financial and quality benchmarks. Key Areas of Responsibility: Strategic Throughput & LOS: Lead initiatives to reduce Average Length of Stay (ALOS) by identifying systemic bottlenecks and implementing proactive discharge planning. Utilization & Revenue Integrity: Oversee the UM Plan to ensure compliance with CMS and payer requirements; manage the peer-to-peer review process and concurrent denial mitigation to protect hospital revenue. Operational Leadership: Direct daily operations, staffing, and budgeting for a multidisciplinary team of RN Case Managers and Social Workers Interdisciplinary Collaboration: Partner with the CMO, CNO, and CFO to align case management with clinical and financial objectives; lead action-oriented multidisciplinary rounds (MDR). Data-Driven Improvement: Analyze KPIs, including readmission rates, cost per case, and bed occupancy, to implement continuous quality improvement strategies. Succession Planning & Talent Development: Proactively identify and mentor high-potential staff to build a robust leadership pipeline. Develop formal cross-training programs and professional development pathways for RN Case Managers and Social Workers to ensure operational continuity and internal promotion readiness.

Requirements

BSN or MSW required. MSN, MBA, or MHA preferred.
Active Pennsylvania RN or LCSW/LMSW license
Extensive leadership experience in and expert knowledge of hospital-based case management, care management, utilization management, discharge planning, social work, patient throughput, transition management, or related area
Demonstrated experience leading interdisciplinary teams in an acute care setting
Demonstrated experience with utilization review, medical necessity, patient status, denial prevention, discharge planning, care transitions, payer requirements, and post acute coordination
Demonstrated experience using operational, clinical, financial, and quality data to drive performance improvement
Strong knowledge of reimbursement methodologies, managed care principles, payer requirements, Medicare, Medicaid, denial prevention, appeals, and patient status determination
Strong understanding of the Centers for Medicare & Medicaid Services Conditions of Participation, utilization review requirements, discharge planning regulations, and applicable accreditation standards, including The Joint Commission
Strong understanding of value-based care, population health, readmission reduction strategies, post acute resource management, and total cost of care
Knowledge of social determinants of health and the clinical, psychosocial, financial, and operational factors that affect progression of care and safe transitions
Excellent communication, collaboration, conflict resolution, and relationship-building skills
Strong leadership, change management, and team development skills
Strong analytical skills with ability to interpret performance data, identify trends, and implement sustainable improvement strategies
Ability to develop effective working relationships with physicians, physician advisors, nursing leaders, ancillary departments, community agencies, and payers
Proficiency with electronic medical records, case management information systems, throughput tools, and reporting platforms

Nice To Haves

MSN, MBA, or MHA preferred.
ACM or CCM strongly preferred. If not certified at time of hire, certification should be obtained within a defined period in accordance with organizational expectations.

Responsibilities

Strategic Throughput & LOS: Lead initiatives to reduce Average Length of Stay (ALOS) by identifying systemic bottlenecks and implementing proactive discharge planning.
Utilization & Revenue Integrity: Oversee the UM Plan to ensure compliance with CMS and payer requirements; manage the peer-to-peer review process and concurrent denial mitigation to protect hospital revenue.
Operational Leadership: Direct daily operations, staffing, and budgeting for a multidisciplinary team of RN Case Managers and Social Workers
Interdisciplinary Collaboration: Partner with the CMO, CNO, and CFO to align case management with clinical and financial objectives; lead action-oriented multidisciplinary rounds (MDR).
Data-Driven Improvement: Analyze KPIs, including readmission rates, cost per case, and bed occupancy, to implement continuous quality improvement strategies.
Succession Planning & Talent Development: Proactively identify and mentor high-potential staff to build a robust leadership pipeline. Develop formal cross-training programs and professional development pathways for RN Case Managers and Social Workers to ensure operational continuity and internal promotion readiness.