Regional Director of Case Management

Apploi; Hartford (CT); On-site; USD 120,000 - 180,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Paid Time Off

Paid Holidays

Career Growth

Job summary

iCare Health Network is seeking a Regional Director of Case Management & Clinical Reimbursement to lead regional efforts in RAI processes, care planning, and compliance. You will maximize reimbursement across Medicare, Medicaid, and commercial programs while guiding facility teams and UR meetings.

The role requires nursing leadership, expertise in PDPM/RUGs, and strong EMR/MS Office skills to drive program development and operational improvements.

Qualifications

• RN with nursing degree and regulatory knowledge.
• Experience with Medicare/Medicaid and RAI processes.
• Experience in hospital or long-term care facility.
• Proficient with EMR systems and MS Office.

Responsibilities

• Provide education, support, and review of Medicare, Medicare Advantage, commercial insurance, and Medicaid cases to maximize reimbursement and maintain compliance.
• Collaborate with Regional Case Managers and facility teams to monitor processes and ensure appropriate follow-through.
• Guide and support Utilization Review meetings at facilities.
• Conduct analytical reviews of PDPM and RUGs reimbursement data for trends and opportunities.
• Respond quickly and effectively in emergency patient care situations.
• Oversee hiring, onboarding, and ongoing education of Case Management nurses.
• Provide continued training related to reimbursement, compliance, and case management processes.

Skills

Regulatory compliance

Medicare/Medicaid knowledge

Leadership

Data analysis

Education

Nursing degree (RN)

Tools

EMR systems

Microsoft Word

Microsoft Excel

Job description

Regional Director of Case Management & Clinical Reimbursement

As a Regional Director of Case Management, you will play a critical role in providing strategic leadership in the RAI process, care planning, compliance, and clinical reimbursement to maximize patient access to insurance benefits and ensure regulatory compliance.

Responsibilities

• Provide education, support, and review of Medicare, Medicare Advantage, commercial insurance, and Medicaid cases to maximize reimbursement and maintain compliance.
• Collaborate with Regional Case Managers and facility teams to monitor processes and ensure appropriate follow-through.
• Provide guidance and support for facility Utilization Review meetings.
• Conduct analytical reviews of PDPM and RUGs reimbursement data to identify trends and opportunities for program development and operational improvement.
• Ability to respond quickly and effectively in emergency patient care situations.
• Oversee the hiring, onboarding, and ongoing education of Case Management nurses
• Provide continued training and support related to reimbursement, compliance, and case management processes

Qualifications

• Must possess a degree in Nursing from an accredited school or be a graduate of an approved RN program.
• RAC certification preferred.
• Experience in a hospital, nursing care facility, or related healthcare facility.
• Working knowledge of Medicare, Medicaid, managed care programs, the RAI process, clinical reimbursement, and compliance regulations and guidelines.
• Experience using Microsoft Word, Excel, and electronic medical record (EMR) systems.

Benefits

• Medical, Dental, and Vision Insurance
• Paid Time Off (PTO)
• Paid Holidays
• Career Growth and Professional Development Opportunities