Market Director of Case Management
Company: Nexus Health Systems Ltd
Location: Houston
Posted on: February 19, 2026
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Job Description:
Job Description Job Description POSITION SUMMARY: The Market
Director of Case Management provides operational and clinical
leadership for all case management, utilization review, and
discharge planning functions across assigned market facilities of
Nexus Health Systems. This role ensures effective care
coordination, regulatory compliance, patient throughput, and
optimal length of stay while aligning market-level execution with
systemwide case management strategy for the market specialty
hospitals with a focus on neurodevelopmental disorders and
co-occurring complex behavioral and medical conditions. The Market
Director partners closely with hospital executives, medical staff,
nursing leadership, and corporate teams to support quality
outcomes, patient experience, and financial performance.
JOB-SPECIFIC RESPONSIBILITIES: • Service o Consistently supports
and communicates the Mission, Vision, and Values of Nexus Health
Systems o Upholds the Standards of conduct and corporate compliance
o Demonstrates honest behavior in all matters. To the best of the
employee’s knowledge and understanding, complies with all Federal
and State laws and regulations. o Maintains the privacy and
security of all confidential and protected health information. Uses
and discloses only that information which is necessary to perform
the function of the job. o Adheres to all Nexus Health Systems
policies on Health Insurance Portability and Accountability Act
(HIPAA), designed to prevent or detect unauthorized disclosure of
Protected Health Information (PHI) o Collaborates effectively with
colleagues and other departments to ensure seamless service
delivery. o Directs the daily operations of the Case Management
Department, ensuring efficient and effective service delivery. o
Facilitates coordination among healthcare teams to develop and
implement comprehensive care plans. o Establishes and nurtures
relationships with insurance providers, healthcare networks, and
community resources to optimize patient care and service delivery.
o Collaborates with the treatment team and patient/family to
prevent duplication or fragmentation of services. • Clinical
Excellence o Lead market-wide case management operations
(screening, assessment, care planning, UR, discharge/transition
planning) and standardize workflows across facilities to meet CMS
Conditions of Participation for Discharge Planning (§482.43) and
Utilization Review (§482.30). o Establish and oversee a Utilization
Review Committee that meets regulatory requirements and integrates
physician advisors for complex determinations. o Implement American
Case Management Association (ACMA)/ Case Management Society of
America (CMSA) standards of practice for care management and
transitions of care. o Apply InterQual® criteria for admission
status, continued stay reviews, discharge readiness, and
level-of-care decisions. o Collaborate with physician advisors to
ensure consistent medical necessity determinations and
documentation quality. o Embed Neurodevelopmental Disabilities
(NDD)-informed care practices (sensory accommodations,
communication supports, caregiver engagement) into case management
workflows. o Use Agency for Healthcare Research and Quality (AHRQ)
care coordination frameworks to align multidisciplinary goals and
transitions. o Provides guidance and support to case managers,
ensuring adherence to best practices and clinical guidelines. o
Monitors patient progress, consulting with healthcare teams to
adjust treatment plans as necessary for optimal outcomes. o Ensures
comprehensive and accurate documentation of patient care,
facilitating continuity and quality of care. o Identifies areas for
clinical improvement and implements strategies to enhance patient
care and service delivery. o Supervises and assists in obtaining
physician documentation in the medical record to support the
current treatment level, medical necessity of continued stay, and
documentation of all current diagnoses being actively treated. o
Collaborates with all interdisciplinary department directors to
coordinate the multidisciplinary treatment plan, identify goals and
interventions, and establish discharge plans appropriate to
medical, legal, and social issues. o Leads the Initial
Multidisciplinary Team Conference and co-chairs ongoing Team
Conferences. o Conducts concurrent and retrospective reviews to
identify and improve clinical, resource, and system problems
utilizing the continuous improvement process. o Recognizes the
importance of documentation improvement and its relation to patient
care and fiscal reimbursement. o Supervises case managers via case
reviews to ensure coordination and finalization of discharge plans,
ensuring services and equipment for safe discharge. o Supervises
department to ensure safety in the workplace and a safe patient
environment at all times. o Reports, coordinates with, and
maintains APS/CPS documentation of potential abuse and neglect in
accordance with Federal, State, and organization policies. o
Provides ongoing supervision of individual case management cases to
ensure appropriate and timely use of medical resources and
discharge planning implementation. o Provides training and
oversight in using ELOS and InterQual as tools to assist in the
appropriate management of patient medical services and facilitate
discharge to the appropriate care level in the most timely and
cost-effective manner. • Patient Experience and Advocacy o Ensure
person-centered discharge planning that reflects patient goals and
includes caregivers as active partners. o Champion patient advocacy
and access principles aligned with Utilization Review Accreditation
Commission (URAC) Case Management Accreditation standards. o
Promote sensory-friendly environments and communication supports
for neurodiverse patients. o Advocates for patients and families,
ensuring their needs and preferences are central to care planning
and delivery. o Leads the development and implementation of
discharge plans, ensuring patients transition smoothly from
hospital to home or other care settings. o Provides guidance on
accessing community resources, financial assistance, and support
services to meet patients' needs. o Oversees the development and
delivery of educational materials and sessions to empower patients
and families in managing health conditions. o Consults, assists,
and intervenes regarding the end-of-life care for patients. o
Advocates for the patient while balancing the responsibility of
stewardship and the judicial management of resources. o Provides
and maintains resource lists for case managers to share with
patients and staff regarding financial and community resources for
all age populations served. • Quality Assurance and Compliance o
Ensures all activities adhere to healthcare regulations and
organizational policies. o Participates in quality improvement
initiatives to enhance service delivery. o Promotes a culture of
patient safety which results in the identification and reduction of
unsafe practices. o Conduct audits for UR and discharge planning
compliance; monitor timeliness, completeness, and appeal outcomes.
o Support accreditation efforts (URAC, ACMA) and embed performance
improvement initiatives. o Leads initiatives to enhance case
management practices, fostering a culture of continuous quality
improvement. o Prepares for and supports accreditation processes,
ensuring all standards and requirements are met. o Ensures
compliance with federal, state, and local regulations, as well as
organizational policies related to case management. • Professional
Growth and Continuing Education o Completes annual education
requirements. o Maintains competency, as evidenced by completion of
competency validation requirements. o Maintains competency and
knowledge of current standards of practice, trends, and
developments. o Participates in relevant workshops, seminars, and
continuing education courses to stay current with industry trends,
healthcare regulations, and best practices. o Oversees the
recruitment, training, and professional development of case
management staff, ensuring they possess the necessary skills and
knowledge. o Provides mentorship and coaching to case managers,
fostering a supportive environment for professional growth. o
Develops and implements educational programs to enhance staff
competencies and keep them abreast of industry trends and best
practices. o Encourages and supports staff in obtaining relevant
certifications to enhance professional credentials. o Develop
competency pathways and leadership development programs for case
management teams. o Encourage staff certification (e.g., CCM,
ACM-RN/ACM-SW, CPHQ) and provide annual training on InterQual®
criteria, CMS CoPs, and NDD-informed care. • Finance: o Promotes
stewardship of hospital resources while ensuring quality patient
care. o Optimize LOS using InterQual® Goal Length of Stay
benchmarks; reduce avoidable days and prevent denials through
proactive medical necessity reviews. o Lead payer engagement and
appeals management in collaboration with physician advisors. o
Monitor throughput, case mix, and financial performance metrics. o
Oversees the allocation of departmental resources, ensuring they
are utilized effectively to meet patient needs and organizational
goals. o Develops and manages the case management department's
budget, ensuring financial resources are allocated effectively. o
Identifies opportunities for cost savings without compromising
patient care, implementing strategies to reduce expenses. o
Prepares financial reports related to case management activities,
providing insights into resource utilization and financial
performance. o Participates in negotiations with insurance
providers and other stakeholders to secure favorable terms for case
management services. o Ensures provision of case management,
utilization management, and discharge planning equally to all
patients regardless of payor source. o Supervises and promotes
appropriate documentation to support medical necessity and resource
use that impacts fiscal reimbursement. o Provides oversight in the
use of tools (e.g., ELOS and InterQual) to facilitate
cost-effective discharge planning. • Performs other duties as
assigned. POSITION QUALIFICATIONS: EDUCATION: • Bachelor’s degree
in Nursing (BSN) or Social Work required • Master’s in Nursing
(MSN), or Master Social Work (MSW) require EXPERIENCE: • Minimum 7
years progressive leadership in hospital case management, including
UR and discharge planning; multi-site experience preferred. •
Experience with neurodevelopmental/behavioral health populations
and complex medical conditions strongly desired. • Strong
analytical and organizational skills • Proficient knowledge of
DNV/Joint Commission accreditation requirements, CMS and state
regulatory requirements and care management and utilization
management. • Proficient in knowledge and ability to apply
professional standards of practice in Case Management, RN, LBSW,
and LMSW practice. SKILLS: • Expert knowledge of CMS CoPs, Joint
Commission standards, and URAC principles. • Proficiency in
InterQual® criteria for medical necessity and level-of-care
determinations. • Strong communication, care coordination, and
advocacy skills; familiarity with NDD-informed practices. • Ability
to apply critical thinking and clinical judgment in diverse and
complex patient scenarios. • Communicates clearly with patients,
families, and healthcare teams, providing updates and support. •
Effective communication skills with both patients and families,
especially in stressful or crisis situations. • Compassionate,
patient-centered approach to care, with the ability to manage
challenging patient behaviors and emotional needs. • Proficient in
managing patients with behavioral health needs. • Strong
organizational skills with the ability to manage multiple tasks
effectively in a dynamic environment. • Prioritizes tasks
efficiently in fast-paced environments and manages multiple patient
needs. • Works effectively with multidisciplinary teams, ensuring
coordinated care. • Adheres to safety protocols, infection control
standards, and best practices. • Competent in using electronic
health record (EHR) systems and medical equipment for patient care
documentation. • Background in business planning, and targeted
outcomes. • Working knowledge of managed care, inpatient,
outpatient, and the home health continuum, as well as utilization •
management and case management. • Working knowledge of the concepts
associated with Performance Improvement. • Demonstrated effective
working relationship with physicians. LICENSURE/CERTIFICATION: •
Current and valid license to practice as a Registered Nurse in the
state of Texas or Current and valid Texas license as a Licensed
Bachelor of Social Worker (LBSW) or Licensed Master of Social
Worker (LMSW) required. • Case Management Certification is required
from accredited professional organization (i.e. ACM, CCM, CMGT,
FAACM). If not currently held at the time of appointment, it must
be obtained within two years. • BLS (Basic Life Support) from
American Heart Association//American Red Cross required, must be
valid for a minimum of 6 months from date of hire. • De-escalation
training within 30 days after hire. • Must maintain current
certification in good standing during employment with this
facility.
Keywords: Nexus Health Systems Ltd, Galveston , Market Director of Case Management, Healthcare , Houston, Texas
