Regional Director, Case Management & Utilization

RiseMe; Town of Florida (NY); On-site; USD 120,000 - 180,000; Full time

Job summary

RiseMe seeks an experienced nurse leader to manage Case Management across HSA hospitals. You will drive utilization performance, ensure compliant processes and optimal resource use, and lead education for physicians, patients, families, and caregivers.

The role focuses on standardizing processes, improving throughput, and achieving appropriate reimbursement while meeting CMS and accreditation requirements.

Qualifications

• Active RN license required.
• At least 5 years acute hospital case management experience.
• MSN and ACM certifications preferred.

Responsibilities

• Oversee department operations to assure throughput and reimbursement.
• Lead the implementation and oversight of Utilization Management Plans.
• Ensure medical necessity review processes comply with CMS and policy.
• Ensure timely patient transitions and planning to support throughput.
• Develop and deliver physician education on hospital utilization.
• Ensure compliance with state/federal regulations and TJC standards.

Skills

RN license

5+ years case management

Leadership

Critical thinking

Communication

Business planning

Education

Active RN license

MSN preferred

ACM preferred

Tools

Allscripts Care Mgmt

CERMe InterQual

McKesson InterQual

Cerner HPF

Crimson

Job description

RiseMe seeks an experienced nurse leader to manage Case Management across HSA hospitals. You will drive utilization performance, ensure compliant processes and optimal resource use, and lead education for physicians, patients, families, and caregivers.

The role focuses on standardizing processes, improving throughput, and achieving appropriate reimbursement while meeting CMS and accreditation requirements.