Director, Case Management

About the role

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.

Responsibilities

• Creates/maintains an environment that attracts strong talent, encourages high/engagement and low turnover, and promotes job satisfaction and retention
• Provides day-to-day oversight of Case Management clinical operations, ensuring all practices and programs are aligned with the overall strategic plan of the organization and follow best-practice standards.
• Sets direction for Case Management staff, ensuring accountability, quality outcomes, and follow-through.
• Analyses various Case Management reports to identify gaps and strengths that support operational deliverables while providing exceptional member care.
• Drive initiatives to reduce preventable admissions and readmissions across targeted lines of businesses.
• Facilitate and participate in committees, task forces, and multidisciplinary teams to promote standardized approaches to care management.
• Maintain oversight of Complex Case Management (CCM), Transition of Care (TOC), and Population Health Management (PHM) programs to ensure compliance with NCQA accreditation standards.
• Oversees member identification, stratification, assessment, care planning, interdisciplinary care team activities, and member engagement activities consistent with NCQA standards.
• Leads preparation and response activities for NCQA surveys, health plan audits, delegated oversight reviews, and regulatory examinations.
• Maintains audit-ready documentation and evidence to support accreditation, delegation, and contractual requirements.
• Collaborates with Quality Management leadership to identify opportunities for performance improvement and implement corrective action plans when necessary.
• Utilizes data analytics to monitor program effectiveness, member outcomes, quality measures, utilization trends, and cost of care.
• Ensures annual evaluation of program effectiveness, including intervention outcomes, member satisfaction, and achievement of established goals.
• Oversees interdisciplinary care team activities involving nursing, social work, behavioral health, pharmacy, and provider partners to ensure comprehensive care coordination across the continuum.
• Ensures members receive individualized care plans addressing clinical, behavioral, psychosocial, and social determinants of health needs.
• Provides leadership and direction to direct reports.

Qualifications

• Strong clinical expertise in care coordination, complex case management, and discharge planning.
• Excellent verbal and written communication skills with ability to convey complex clinical and operational concepts clearly.
• Demonstrated ability to lead interdisciplinary teams in a fast-paced, high-volume environment.
• Strong analytical, critical thinking, and problem-solving skills.
• Ability to perform comprehensive assessment of physical and psychosocial needs of patients.
• Proven ability to manage multiple priorities under tight deadlines.
• Experience with process improvement and performance optimization initiatives.
• Ability to build strong relationships and collaborate effectively across clinical and non-clinical stakeholders.
• Experience managing delegated health plan programs and participating in delegation audits.
• Knowledge of Medicare, Medicaid, Commercial, and Managed Care regulatory requirements.
• Thorough knowledge of NCQA Population Health Management (PHM), Complex Case Management (CCM), and Transition of Care standards.
• Understanding of utilization management, risk management, and compliance standards.
• Ability to develop and execute operational strategies aligned with organizational goals.

Training/Education

• Graduate of an accredited nursing or health-related program required; Master’s Degree preferred.
• Current RN license required; BSN preferred.
• CCM certification required.
• Strong clinical assessment skills, including physical and psychosocial evaluation of patients.
• Direct acute care clinical experience preferred.

Experience

• 7+ years of progressive leadership experience in healthcare, managed care, or care coordination settings.
• 5+ years of experience in case management, discharge planning, or care transitions.
• 3-5+ years of experience in supervisory or line management roles overseeing clinical operations.
• Demonstrated experience leading care management or utilization management teams.
• Experience managing process improvement and care transition initiatives.
• Strong background in discharge planning, transitional care, and reduction of readmissions.

Pay

Base Compensation: $130,000 - $150,000 annually

Schedule

N/A