Community Behavioral Health Clinic Program Manager

ICP Solutions Limited; Cranston (RI); On-site; USD 120,000 - 180,000; Full time

Job summary

The Rhode Island BHDDH is seeking an experienced Director of Case Management to lead the Case Management Program at Eleanor Slater Hospital and oversee hospital-wide case management, utilization management, discharge planning, and care coordination.

This role requires RN licensure in Rhode Island and a proven track record in leadership, program oversight, and regulatory compliance within acute care settings. Strong collaboration with payers, providers, and interdisciplinary teams is essential.

Qualifications

• BSN from an accredited program
• Current unrestricted RN license in Rhode Island
• 5+ years clinical case management in acute care
• Experience with insurance authorization processes (pre-auths, denials, appeals)
• Leadership of multidisciplinary teams
• Strong knowledge of reimbursement and discharge planning

Responsibilities

• Provide leadership for hospital case management and utilization management
• Develop and monitor policies, procedures, and performance metrics for compliance
• Oversee quality improvement and performance initiatives
• Participate in interdisciplinary rounds and coordinate individualized care plans
• Oversee discharge planning and care coordination with post-acute providers
• Direct insurance authorizations and payer relations, including denials and appeals
• Ensure compliance with regulatory requirements and confidentiality standards

Job description

The Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & Hospitals (BHDDH) is seeking an experienced Director of Case Management to lead and support the continued expansion of the Case Management Program at Eleanor Slater Hospital.

This leadership role is responsible for overseeing hospital-wide case management, utilization management, discharge planning, and care coordination activities while ensuring high-quality, patient-centered, and cost-effective healthcare services.

Essential Duties and Responsibilities

Leadership and Program Oversight

• Provide leadership, direction, and operational oversight for hospital case management and utilization management services.
• Develop, implement, and monitor policies, procedures, and performance metrics to ensure compliance with organizational goals and regulatory standards.
• Evaluate departmental operations to ensure quality, efficiency, and alignment with industry best practices.
• Participate in departmental and organizational quality improvement initiatives and performance improvement activities.
• Serve as a subject matter expert and resource regarding case management, utilization review, discharge planning, and care coordination.

Clinical Case Management

• Participate in interdisciplinary patient care rounds to assess patient needs and coordinate individualized care plans.
• Identify high-risk patients and collaborate with the healthcare team to develop targeted interventions that promote positive clinical outcomes.
• Facilitate coordinated care services and remove barriers to timely treatment and discharge.
• Collaborate with the Patient Resources and Benefits Division to support financial and benefits-related patient needs.
• Ensure appropriate patient handoffs and transitions between levels of care through effective communication and documentation.
• Review clinical information and apply appropriate clinical criteria, guidelines, policies, and professional judgment to support level-of-care determinations and utilization review decisions.
• Oversee concurrent and retrospective reviews of medical records to ensure appropriate utilization of services and compliance with utilization management standards.
• Monitor patient length of stay and collaborate with physicians, patients, families, and care teams to support medically appropriate and timely discharge planning.
• Utilize InterQual®, Milliman Care Guidelines (MCG), and other evidence-based criteria to support utilization review activities.

Discharge Planning and Care Coordination

• Develop and maintain relationships with post-acute providers and community resources to facilitate smooth patient transitions.
• Partner with Social Work and other interdisciplinary team members to ensure timely and appropriate discharge plans.
• Educate patients and families regarding discharge options, insurance considerations, and available resources.
• Advocate for patients while balancing clinical, financial, and regulatory requirements.

Insurance Authorization and Payer Relations

• Direct and oversee insurance authorization activities, including pre-authorizations, continued stay reviews, post-acute placements, and ancillary services.
• Ensure timely submission of clinical documentation and compliance with payer requirements.
• Collaborate with payers, providers, and internal stakeholders to resolve authorization denials and barriers to care.
• Participate in peer-to-peer reviews and appeals processes, as necessary, to support appropriate patient care and reimbursement.

Compliance and Regulatory Responsibilities

• Ensure compliance with all applicable federal, state, and local regulations governing case management and utilization review services.
• Maintain adherence to organizational policies, accreditation standards, and confidentiality requirements.
• Monitor emerging healthcare regulations and reimbursement requirements to ensure ongoing compliance and operational effectiveness.

Minimum Qualifications

• Bachelor of Science in Nursing (BSN) from an accredited nursing program.
• Current unrestricted Registered Nurse (RN) license in the State of Rhode Island.
• Minimum of five (5) years of progressive clinical case management and/or utilization management experience in an acute care or hospital setting.
• Demonstrated experience managing insurance authorization processes, including pre-authorizations, concurrent reviews, denials, and appeals.
• Proven leadership experience overseeing complex healthcare operations and multidisciplinary teams.
• Strong knowledge of healthcare reimbursement methodologies, utilization review practices, and discharge planning processes.
• Demonstrated ability to exercise sound independent judgment and make complex decisions in a fast-paced healthcare environment.
• Experience handling highly sensitive and confidential information in accordance with applicable laws and organizational policies.
• Excellent organizational, communication, interpersonal, and collaboration skills.
• Proficiency with Microsoft Office Suite and healthcare information systems.

Preferred Qualifications

• Certification in Case Management (CCM, ACM, or equivalent) from a nationally recognized organization.
• Three (3) or more years of leadership or supervisory experience in hospital case management.
• Experience in a long-term acute care hospital (LTACH), rehabilitation hospital, or state-operated healthcare setting.
• Strong working knowledge of InterQual® and Milliman Care Guidelines (MCG).
• Experience with quality improvement initiatives, regulatory surveys, and accreditation standards.
• Master's degree in nursing, Healthcare Administration, Public Health, or a related field.

Strategic Leadership

Clinical Operations Management

Regulatory Compliance

Quality Improvement

Stakeholder Collaboration

Problem Solving and Decision Making

Communication and Relationship Management

Assignment Lenth: At least 1 year but most likely longer with good chance to convert to FTE

Work Location

This position is an onsite role supporting both Eleanor Slater Hospital campuses. Travel between campuses may be required.