Case Manager Lead

Job Summary

The Lead Case Manager provides daily operational oversight for Case Management and Utilization Review functions within the hospital. This role ensures effective coordination of patient care through the continuum, acting as a subject matter expert, mentor, and educator for the case management team. The Lead Case Manager promotes resource efficiency, regulatory compliance, and high-quality patient transitions while facilitating communication between interdisciplinary care teams, payors, and external partners.

Essential Functions

• Care Coordination: Lead the daily coordination of patient care, treatment planning, and resource utilization.
• Participate in patient care rounds and interdisciplinary team (IDT) meetings.
• Maintain expertise in case management practices, reimbursement models, and psychosocial support.
• Refer high-risk patients for additional services as needed and advocate for patient and family involvement in care decisions.
• Monitor care across the continuum to promote seamless transitions and cost-effective service delivery.
• Discharge Planning: Perform ongoing assessments to identify discharge needs and barriers.
• Coordinate timely and comprehensive discharge plans in collaboration with patients, families, and the care team
• Communicate discharge expectations and ensure follow-through with internal and external partners.
• Utilization Management: Conduct concurrent medical necessity reviews to validate appropriate service use.
• Collaborate with payors for continued stay authorizations and care coordination.
• Support documentation and compliance with CMS, Joint Commission, and internal standards.
• Leadership & Staff Support: Serve as a mentor and preceptor for case management staff.
• Educate team members on best practices, discharge planning, and resource utilization.
• Collaborate with the Director of Case Management to maintain regulatory compliance and readiness for audits.
• Other Responsibilities: Participate in hospital or division-level committees as requested.
• Uphold the organization’s Code of Conduct, compliance policies, and applicable professional standards.
• Complete documentation accurately and in a timely manner.
• Perform other related duties as assigned.

Knowledge/Skills/Abilities/Expectations

• Strong knowledge of Medicare, Medicaid, and commercial payor guidelines.
• Familiarity with accreditation standards and state/federal healthcare regulations.
• Proficient in Microsoft Office and electronic health record (EHR) systems.
• Strong critical thinking, prioritization, and time management skills.
• Excellent written and verbal communication and interpersonal skills.
• Ability to work collaboratively across departments and disciplines.

Education

• Postsecondary (Cert/Diploma/Program Grad) from an accredited program (Required)
• Bachelor’s Degree in Nursing (Preferred)
• Bachelor’s Degree in Social Work (May be Required-Facility Specific)
• Master’s Degree in Social Work (May be Required-Facility Specific)

Licenses/Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure or LCSW or LSW in state of practice Upon Hire (Required)
• CCM - Certified Case Manager Upon Hire (Preferred)

Experience

• 2+ years experience in healthcare setting (Required) And
• Prior Experience in case management, utilization review, or discharge planning (Preferred) And

• Prior Experience in acute care or long-term acute care hospital (LTACH) (Preferred)