Director of Case Management, Revenue Integrity

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Lead and oversee the corporate Case Management program across designated facilities.

• Develop strategies, policies, standardized workflows, education, competency expectations, performance monitoring, and operational support.

• Ensure patient-centered discharge planning is compliant and facilitate timely transitions of care.

• Evaluate and escalate complex discharge barriers, avoidable delays, readmissions, and care-transition issues.

• Collaborate with Utilization Review leadership while ensuring independence from UR ownership and decisions.

• Design, implement, and sustain the enterprise Revenue Integrity program.

• Create and manage risk-based audits concerning charge capture, billing, claim edits, revenue codes, modifiers, units, duplicate or missing charges, and related risk areas.

• Oversee audits and verify billed services against health records, documentation, payer requirements, policy, and billing guidelines.

• Collaborate with Coding, CDI, HIM, Patient Financial Services, Finance, clinical departments, IT, and Compliance to address corrective actions.

• Establish governance for charge-capture and chargemaster-related integrity initiatives.

• Identify, assess, analyze trends, and escalate overpayments, underpayments, duplicate billing, unsupported charges, and compliance issues.

• Maintain objective audit workpapers, sampling methods, findings, financial impacts, corrective actions, responsible parties, deadlines, and validation results.

• Create dashboards and report on the performance, risks, financial impact, barriers, and value of Case Management and Revenue Integrity programs.

• Monitor adherence to regulatory, payer, CMS, OIG, privacy, and information-security standards.

• Select, develop, evaluate, mentor, and oversee assigned staff.

• Manage strategic objectives, budget suggestions, vendor relationships, productivity expectations, and resource requirements.

• Represent the functions in multidisciplinary committees, leadership meetings, and workgroups.

⛳️ Requirements

• Bachelor's degree in Nursing, Social Work, Health Information Management, Healthcare Administration, Business, Revenue Cycle, or a closely related field is required.

• A 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 is required.

• At least three (3) years of leadership, management, audit, education, or multi-facility program oversight experience is necessary.

• Proven experience in conducting revenue integrity or billing-compliance audits and executing corrective actions is required.

• Advanced understanding of acute-care discharge planning, care coordination, transitions of care, complex case escalation, post-acute placement, patient choice, and readmission/avoidable-delay analysis.

• Advanced expertise in hospital charge capture, chargemaster concepts, revenue codes, modifiers, claim edits, inpatient and outpatient billing workflows, and reimbursement methodologies.

• Working knowledge of CMS Hospital Conditions of Participation, Medicare and Medicaid requirements, HIPAA, fraud/waste/abuse principles, overpayment obligations, payer requirements, and relevant state regulations.

• Capability to design risk-based audit plans, define samples and criteria, document reproducible findings, quantify financial impact, identify root causes, and validate corrective actions.

• Proficient in collecting, analyzing, trending, and presenting operational, clinical, financial, and audit data.

• Demonstrated ability to develop programs, teams, policies, tools, metrics, and governance frameworks.

• Proficient in Microsoft Office applications.

• Familiarity with electronic medical records, case management systems, hospital patient-accounting/billing systems, claim-scrubber/edit tools, and data analytics or audit software.

• Must be willing to travel nationally as required.

• A current unrestricted RN, social work, or other applicable professional license is required only when assigned duties involve licensed practice.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional growth and career advancement.

• Supportive work atmosphere with a collaborative team.

• Comprehensive healthcare coverage.

• Retirement savings plan.

• Paid time off and flexible scheduling options.

• Student loan repayment program.