Director of Case Management and Revenue Integrity

Director of Case Management and Revenue Integrity

Position Details:
Employment Type:  Full Time
Location:  Remote
Reports to:  AVP of Middle Revenue Cycle & Special Projects

Job Summary:

The Director of Case Management & Revenue Integrity is a key leadership role within Mid-Revenue Cycle and Clinical Operations. The Director provides corporate oversight of patient-centered Case Management, including discharge planning, care coordination, transitions of care, complex case escalation, and removal of avoidable barriers to safe and timely discharge. The Director also builds and leads the enterprise Revenue Integrity program, including a risk-based audit strategy and Revenue Integrity team, to promote accurate and compliant charge capture and billing, identify potential overpayments and underpayments, and drive corrective action. This position does not own, conduct, or direct Utilization Review (UR), medical-necessity review, or patient-status determinations, but collaborates closely with UR and with Coding, CDI, HIM, Patient Financial Services, Compliance, Quality, Finance, clinical leaders, physicians, and facility administration.

Key Responsibilities:

• Directs and manages the corporate Case Management program, including strategy, policies, standardized workflows, education, competency expectations, performance monitoring, and operational support across assigned facilities.
• Ensures case management processes support an effective, patient-centered discharge planning program consistent with applicable CMS Conditions of Participation, state law, accreditation requirements, payer requirements, and organizational policy.
• Promotes early identification of patients who may experience adverse consequences without adequate discharge planning and supports timely discharge planning evaluations, re-evaluations, and updates as patient needs change.
• Ensures discharge planning activities address patient goals and treatment preferences, caregiver/support-person participation, post-acute service needs and availability, access barriers, patient choice, and the timely transmission of information necessary for safe transitions of care.
• Ensures discharge planning evaluations and plans are developed by, or under the supervision of, appropriately qualified personnel in accordance with federal and state requirements and organizational policy.
• Collaborates with facility leadership to support compliant patient transfer processes, post-acute placement practices, freedom-of-choice requirements, and education of staff regarding applicable transfer and discharge-planning policies.
• Leads analysis and escalation of complex discharge barriers, avoidable delays, readmissions, care-transition concerns, and other case management trends; develops action plans that improve patient flow without compromising patient rights, safety, or appropriate care.
• Builds productive relationships with physicians, nursing, social work, post-acute providers, Quality, Risk Management, Compliance, and facility executives to advance safe, efficient, and patient-centered care transitions.
• Collaborates closely with Utilization Review leadership regarding medical-necessity review, patient-status processes, payer authorization requirements, denial prevention, and related workflows while maintaining clear separation of accountability; this role does not own, conduct, or direct the hospital's UR plan or UR determinations.
• Designs, implements, and maintains the enterprise Revenue Integrity program, including organizational structure, staffing model, job roles, recruitment, onboarding, training, audit standards, work queues, escalation pathways, and performance metrics.
• Develops and executes a documented, risk-based Revenue Integrity audit plan using approved methodologies for prospective and retrospective review of inpatient and outpatient charge capture, billing, claim edits, revenue codes, modifiers, units, duplicate or missing charges, and other assigned billing-integrity risk areas.
• Performs and/or directs Revenue Integrity audits and validates that billed services are supported by the health record, applicable charging documentation, payer requirements, organizational policy, and authoritative billing guidance; does not alter the health record or direct unsupported coding or billing changes.
• Partners with Coding, CDI, HIM, Patient Financial Services, Finance, clinical departments, Information Technology, and Compliance to evaluate root causes of audit findings and implement sustainable corrective actions, education, system edits, workflow changes, and monitoring.
• Establishes governance for assigned charge-capture and chargemaster-related integrity activities, including review of charge logic, revenue-code alignment, billing edits, and department charging practices in collaboration with designated operational owners.
• Identifies, quantifies, trends, and escalates potential overpayments, underpayments, duplicate billing, unsupported charges, or other compliance concerns; promptly refers potential overpayments or fraud, waste, or abuse concerns through established Compliance/Legal channels and supports required investigation, correction, refund, or disclosure activities.
• Maintains objective audit workpapers, sampling methodology, findings, financial impact, corrective-action plans, responsible owners, due dates, and validation results sufficient to support internal and external review.
• Develops dashboards and regularly reports Case Management and Revenue Integrity performance, risk trends, financial impact, operational barriers, corrective actions, and program value to facility and corporate leadership.
• Develops, implements, and monitors policies and procedures that support compliant case management, discharge planning, revenue integrity, billing, auditing, privacy, and information-security practices.
• Monitors and communicates changes in federal and state laws, CMS regulations and guidance, OIG compliance guidance and Work Plan risk areas, payer requirements, and other authoritative standards that affect assigned Case Management and Revenue Integrity operations.
• Protects the confidentiality, integrity, and security of protected health information; accesses, uses, and discloses information only as necessary to perform assigned duties and in accordance with HIPAA, organizational policy, and applicable law.
• Promotes a culture of ethical conduct, non-retaliation, and prompt reporting of suspected compliance concerns; supports corrective action through established channels.
• Selects, develops, evaluates, coaches, and manages assigned staff; makes or effectively recommends personnel decisions consistent with delegated authority and organizational policy.
• Develops and manages strategic operating goals, budget recommendations, vendor relationships, productivity expectations, and resource needs for assigned Case Management and Revenue Integrity functions.
• Represents Case Management and Revenue Integrity on multidisciplinary committees, leadership meetings, and work groups and serves as a corporate subject matter resource within the scope of the role.

Required Skills & Qualifications:

• Leadership - leads individuals and teams toward defined outcomes, sets clear standards, manages accountability, and builds a high-performing service culture.
• Case Management - advanced knowledge of acute-care discharge planning, care coordination, transitions of care, complex case escalation, post-acute placement, patient choice, and readmission/avoidable-delay analysis.
• Revenue Integrity - advanced knowledge of hospital charge capture, chargemaster concepts, revenue codes, modifiers, claim edits, inpatient and outpatient billing workflows, and reimbursement methodologies.
• Regulatory and Compliance - working knowledge of CMS Hospital Conditions of Participation, Medicare and Medicaid requirements, HIPAA, fraud/waste/abuse principles, overpayment obligations, payer requirements, and applicable state scope-of-practice and discharge-planning requirements.
• Utilization Review Collaboration - understands the interface between Case Management and UR and can coordinate workflows without assuming responsibility for UR committee functions, medical-necessity review, or patient-status determinations assigned to the UR structure.
• Auditing and Monitoring - ability to design risk-based audit plans, define samples and criteria, document reproducible findings, quantify financial impact, identify root cause, and validate corrective action.
• Data Analytics - advanced ability to collect, analyze, trend, and present operational, clinical, financial, and audit data; translates findings into actionable recommendations.
• Strategic Program Development - demonstrated ability to build programs, teams, policies, tools, metrics, and governance structures from initial design through sustained operations.
• Critical Thinking and Decision Making - independently evaluates complex facts, considers regulatory and operational risk, exercises discretion on significant matters, and escalates issues appropriately.
• Communication and Facilitation - communicates clearly and professionally with executives, facility leaders, physicians, clinicians, auditors, payers, vendors, and staff; facilitates difficult conversations and multidisciplinary problem solving.
• Relationship Management - builds and maintains effective working relationships across corporate and facility departments while preserving role clarity and compliance accountability.
• Change Management - leads implementation of standardized workflows and process improvement across multiple facilities and adapts to changing regulatory, payer, and organizational requirements.
• Technology - proficient with Microsoft Office applications and able to work effectively with EMR, case management, patient accounting, claim-scrubber, coding/billing, audit, and analytics platforms.
• Confidentiality and Objectivity - maintains privacy, security, professional ethics, independence, and accurate documentation when performing audits, reviewing patient information, or reporting compliance concerns.

Work Experience, Education and Certifications:

• Education:
  • Bachelor's degree in Nursing, Social Work, Health Information Management, Healthcare Administration, Business, Revenue Cycle, or a closely related field required.
  • Master's degree in Nursing, Social Work, Healthcare Administration, Business, Health Informatics, or a related field preferred.
  • An equivalent combination of education, relevant professional credentials, and leadership experience may be considered with executive and Human Resources approval.
• Certification/Licensure:
  • Current unrestricted RN, social work, or other applicable professional license is preferred and is required only when the individual's assigned duties constitute licensed clinical or social work practice under applicable state law or organizational policy.
  • When functioning under a professional license, the employee must maintain all required state, compact, and/or multistate privileges applicable to the work performed.
• Preferred Credentials:
  • ACM, CCM, CMAC, CHC, CRCR, CRCE, RHIA, RHIT, CCS, CPC, or another recognized credential relevant to case management, compliance, health information, coding, or revenue cycle operations.
  • A combination of case management and revenue integrity/compliance expertise is strongly preferred.
• Experience:
  • Minimum of seven (7) years of progressive acute-care hospital experience in Case Management, Revenue Integrity, Revenue Cycle, HIM/Coding, Compliance, Clinical Operations, or a closely related field required, including at least three (3) years of leadership, management, audit, education, or multi-facility program oversight.
  • Demonstrated experience conducting revenue integrity or billing-compliance audits and implementing corrective actions is required. Corporate or multi-facility leadership experience is strongly preferred.
• Software/Hardware:
  • Proficiency with Microsoft Office applications; experience with electronic medical records, case management systems, hospital patient-accounting/billing systems, claim-scrubber/edit tools, and data analytics or audit software.
• Other:
  • Remote corporate position.
  • The ideal candidate has a strong acute-care Case Management foundation, direct experience with hospital revenue integrity auditing, demonstrated success building or redesigning teams and programs, and the ability to operate effectively across clinical, regulatory, operational, and financial disciplines.
• Travel Requirements:
  • Must be able to travel nationally as needed.

Benefits:

• Competitive salary and benefits package.
• Opportunities for professional development and advancement.
• Supportive work environment with a collaborative team.
• Comprehensive healthcare coverage.
• Retirement savings plan.
• Paid time off and flexible scheduling options.
• Student loan repayment program.