Director of Case Management & Utilization Review

Nexus Health Systems Ltd; Houston (TX); On-site; USD 150,000 - 210,000; Full time

Job summary

Nexus Health Systems in Houston, TX seeks an experienced Corporate Director of Case Management and Utilization Review to lead these functions across our multi-facility health system. This executive will oversee case management, utilization review, care coordination, discharge planning, and transitions of care.

You will drive unified workflows, ensure medical necessity alignment with payer requirements, and set shared performance goals across facilities.

Qualifications

• BSN and MSN required.
• Minimum seven years of progressive hospital case management leadership.
• Experience leading multi-site operations across facilities.
• Expertise in medical necessity review and utilization management.
• Current Texas RN license; case management certification within two years if not held.

Responsibilities

• Develop and execute a unified strategy connecting Case Management and UR across Nexus facilities.
• Define responsibilities and handoffs between Case Management, UR, clinical teams, and revenue cycle to support coordinated care.
• Oversee admission and continued-stay reviews, authorization workflows, and communication with payers.
• Lead care coordination, discharge planning, and transitions of care across facilities.
• Monitor length of stay, denial trends, and implement corrective actions to improve outcomes and efficiency.
• Develop and manage departmental budgets, staffing plans, and resource allocation.

Skills

Leadership

Strategic thinking

Analytical skills

Communication

Change management

Interdisciplinary collaboration

Education

BSN

MSN

Tools

InterQual

EHR systems

Job description

Nexus Health Systems in Houston, TX seeks an experienced Corporate Director of Case Management and Utilization Review to lead these functions across our multi-facility health system. This executive will oversee case management, utilization review, care coordination, discharge planning, and transitions of care.

You will drive unified workflows, ensure medical necessity alignment with payer requirements, and set shared performance goals across facilities.