Director of Centralized Case Management

CareOne•Fort Lee, NJ

About The Position

The Director of Centralized Case Management oversees managed care authorizations at skilled and custodial levels to ensure accuracy, timeliness, and compliance. The role supports Denials Management by reviewing denials and audit requests, coordinating documentation and follow-up, and tracking issues through resolution. The Director leads the Managed Care Coordinator and Centralized Case Management team, improves processes, and safeguards reimbursement integrity. The position collaborates with executive leadership, interdisciplinary teams, payers, and external partners to optimize workflows, reduce errors, and support financial and operational excellence. The Director develops and implements streamlined authorization and custodial case-management processes; conducts authorization reviews and audits; monitors the daily AR tab in PCC; and helps train new Case Managers in PCC, MCM, departmental policies, and best practices. The role leads the design and implementation of a centralized team and standardized workflows, supports Medicare denials, appeals, RAC reviews, and TPE audits, and serves as a liaison with Denials Management. It also identifies trends and supports education and corrective actions, resolves escalated issues, and provides coverage for the Managed Care Coordinator role. A bachelor’s degree in health administration, business administration, nursing, or a related field is required. Candidates must have 3–5 years of experience in managed care, healthcare administration, or a related field, including direct experience with insurance authorizations and reimbursement processes. Experience with multiple managed care plans, contracts, and provider portals, as well as familiarity with HIPAA and CMS guidelines, is required. Prior supervisory or leadership experience is preferred.

Requirements

Bachelor’s degree in health administration, business administration, nursing, or a related field.
3–5 years of experience in managed care, healthcare administration, or a related field, including direct experience with insurance authorizations and reimbursement processes.
Experience working with multiple managed care plans, understanding contracts, and navigating provider portals.
Strong familiarity with regulatory compliance, healthcare policies, and procedures, including HIPAA and CMS guidelines.
In-depth knowledge of managed care authorization processes, payer requirements, local managed care insurance, contracts, reimbursement processes, and applicable regulations.
Knowledge of denials management and RAC audit processes, including documentation requirements, follow-up, and timely resolution.
Strong leadership, organizational, and staff-training abilities.
Exceptional attention to detail and ability to manage multiple priorities and ensure timely follow-through.
Effective verbal and written communication, interpersonal, collaboration, and relationship-building skills.
Ability to analyze performance, identify trends, make sound decisions, and implement process improvements.
Critical-thinking and problem-solving skills, including the ability to assess and address issues in real time while collaborating with provider relations teams.
Ability to interpret and apply standard operating procedures and compliance requirements.
Ability to exercise independent judgment and make decisions aligned with organizational goals.
Ability to foster collaboration, teamwork, and mutual respect.
Commitment to confidentiality and professional handling of sensitive information.

Nice To Haves

Prior supervisory or leadership experience, with a track record of training, mentoring, or managing staff.

Responsibilities

Oversee managed care authorization processes at skilled and custodial levels to ensure accurate, timely, and compliant authorizations.
Support Denials Management by reviewing denials and audit requests, coordinating documentation and follow-up, and tracking issues through resolution.
Lead the Managed Care Coordinator and Centralized Case Management team; train, mentor, and support staff.
Develop and implement streamlined managed care authorization and custodial case-management processes to reduce errors and improve reimbursement timelines.
Review and audit authorizations for accuracy, compliance, and proper documentation of approved lengths of stay.
Proactively monitor and audit the daily AR tab in PCC to support timely, accurate authorization entry and on-time reimbursement.
Partner with the Chief Clinical Officer or designee to train new Case Managers on PCC, MCM, departmental policies, and best practices.
Lead the design and implementation of a centralized case-management team, standardizing workflows and improving cross-department communication.
Partner with the Denials Management lead on Medicare denials, appeals, RAC reviews, and TPE audits, providing clinical and case-management support, documentation review, and operational follow-up.
Serve as a liaison between Centralized Case Management and Denials Management, escalating Medicare audit findings, documentation concerns, and appeal-related issues requiring case-management intervention.
Identify trends involving Medicare medical necessity, documentation, and utilization practices, and assist with education and corrective actions across the case-management team.
Serve as the escalation lead for centralized case management, resolving complex issues and ensuring client satisfaction.
Provide coverage for the Managed Care Coordinator role to maintain operational continuity and service quality.
Monitor performance metrics, identify trends, and implement process improvements.
Maintain compliance with best-practice standards for contracts and authorizations.
Plan, organize, develop, and implement departmental programs, goals, objectives, policies, and procedures.
Build and maintain positive working relationships with internal teams, external providers, payers, and stakeholders.
Handle sensitive information confidentially and interact professionally and respectfully with staff, residents, families, visitors, regulatory agencies, and the public.