Director of Centralized Case Management

POSITION SUMMARY: Centralized Case Management is responsible for overseeing all aspects of the managed care authorization process to ensure accurate, timely, and compliant authorizations at both skilled and custodial levels. Supports the Denials Management Department by reviewing denials and audit requests, coordinating required documentation and follow-up, and tracking issues through resolution. This role provides leadership to the Managed Care Coordinator and Centralized Case Management team, drives process improvements, and safeguards reimbursement integrity. The Director collaborates closely with executive leadership, interdisciplinary teams, and external partners to optimize workflows, reduce errors, and ensure financial and operational excellence.

RESPONSIBILITIES/ACCOUNTABILITIES:

• Strong knowledge of managed care authorization processes, payer requirements, and regulatory guidelines.
• Proven leadership and team management skills with the ability to train, mentor, and support staff.
• Exceptional organizational skills and attention to detail to ensure timely and accurate authorization management.
• Effective communication and collaboration with internal departments, payers, and external partners.
• Analytical ability to monitor performance metrics, identify trends, and implement process improvements.
• In-depth knowledge of managed care contracts, business processes, and their impact on accounts receivable.
• Skilled in training, educating, and motivating staff on managed care processes.
• Committed to ensuring compliance with best-practice standards for contracts and authorizations.
• Develop and implement streamlined processes for managed care authorizations and custodial case management, reducing errors and improving reimbursement timelines.
• Conduct reviews and audits of authorizations to ensure accuracy, compliance, and proper documentation for approved lengths of stay.
• Proactively monitor and audit the daily AR tab in PCC to ensure timely and accurate entry of authorizations, consistently supporting on time reimbursements.
•  Partner with the Chief Clinical officer or other designee to train new Case Managers on PCC, MCM, departmental policies, and best practices, enhancing onboarding and performance.
•  Lead the design and implementation of a centralized case management team, standardizing workflows and strengthening cross-department communication to accelerate reimbursement turnaround.
• 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 as needed.
• Serve as a key liaison between centralized case management and Denials Management, ensuring timely escalation of Medicare audit findings, documentation concerns, and appeal-related issues that require case management intervention.
• Support Denials Management in identifying trends related to 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.

SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:

• Bachelor’s degree in health administration, Business Administration, Nursing, or a related field required.
• Minimum of 3–5 years of experience in managed care, healthcare administration, or a related field, with direct experience in insurance authorizations and reimbursement processes.
• Demonstrated experience working with multiple managed care plans, understanding contracts, and navigating provider portals.
• Strong familiarity with regulatory compliance, healthcare policies, and procedures (e.g., HIPAA, CMS guidelines).
• Prior supervisory or leadership experience preferred, with a track record of training, mentoring, or managing staff.

JOB SKILLS:

• In-depth knowledge of local managed care insurances, contracts, and reimbursement processes, including applicable regulations.
• Knowledge of denials management and RAC audit processes, including documentation requirements, follow-up, and timely resolution.
• Demonstrated excellence in both verbal and written communication, with strong interpersonal skills to engage effectively across all levels of the organization.
• Proven ability to establish, build, and maintain positive working relationships with internal teams, external providers, and key stakeholders.
• Strong organizational abilities, with a demonstrated capacity to manage multiple priorities and ensure timely follow-through.
• Skilled in critical thinking and quick decision-making, with the ability to assess and address issues in real time while collaborating with provider relations teams.
• Ability to foster an atmosphere of collaboration, teamwork, and mutual respect both internally and externally.
• Commitment to maintaining confidentiality and handling sensitive information with discretion and professionalism.
• Proficiency in interpreting and applying standard operating procedures and compliance requirements.
• Independent judgment and problem-solving skills, with the ability to make sound decisions in alignment with organizational goals.
• Experience in planning, organizing, developing, and implementing departmental programs, goals, objectives, policies, and procedures.
• Ability to positively interact with staff, residents, family members, visitors, regulatory agencies, and the general public in a professional and respectful manner.