Director Denial Prevention Jobs (NOW HIRING)

Nexus Health Systems

Nexus Health Systems is seeking an experienced, strategic healthcare leader with strong expertise in both Case Management and Utilization Review (UR) to lead these functions across our health system. This leader will bring the strategic foresight and operational experience needed to establish unified processes that balance patient outcomes, regulatory compliance, operational efficiency, and financial stewardship.

Demonstrated leadership across both Case Management and UR, along with experience standardizing operations across multiple facilities, is required.

Nexus Health Systems is a multi-facility healthcare organization specializing in complex medical, neurobehavioral, rehabilitation, and behavioral healthcare services for pediatric and adult populations. Our mission-driven teams deliver compassionate, individualized care to patients with complex needs, helping improve quality of life for patients and families.

The Corporate Director of Case Management & Utilization Review provides strategic direction and operational oversight for system-wide case management, utilization review, care coordination, discharge planning, and transitions of care.

This leader will bridge Case Management and UR through consistent workflows, shared performance goals, and clear accountability across facilities. The role requires a strong understanding of how medical necessity, clinical documentation, payer requirements, discharge barriers, and length of stay affect patient outcomes and organizational financial performance.

Working collaboratively with physicians and clinical, operational, and revenue cycle leaders, the Corporate Director will drive medical necessity review, denial prevention, proactive discharge planning, and appropriate resource utilization. This individual must be able to assess current operations, anticipate future needs, and translate strategy into measurable improvements across the health system.

• Develop and execute a unified strategy connecting Case Management and UR across Nexus facilities.
• Assess current operations, identify gaps and variation, and implement standardized policies, workflows, escalation procedures, and performance expectations.
• Define responsibilities and handoffs between Case Management, UR, clinical teams, and revenue cycle to support coordinated care throughout the patient stay.
• Anticipate changes in patient needs, payer practices, and operational demands, and recommend improvements to staffing, resources, and processes.
• Partner with executive and facility leadership to align care management priorities with organizational goals.

• Oversee admission and continued-stay reviews, authorization workflows, and timely communication with payers.
• Promote consistent application of InterQual® criteria and applicable medical necessity requirements.
• Collaborate with physicians and physician advisors to resolve medical necessity concerns, strengthen documentation, and support appropriate utilization.
• Establish clear escalation processes for authorization delays, adverse determinations, and complex utilization issues.
• Oversee Utilization Management Committee activities and follow-through on improvement opportunities.

• Lead care coordination, discharge planning, and transition-of-care processes across facilities.
• Ensure discharge planning begins early and addresses clinical, behavioral, social, caregiver, and placement needs.
• Drive interdisciplinary review of discharge barriers and length of stay to reduce avoidable days while supporting safe, appropriate transitions.
• Strengthen coordination with families, caregivers, community resources, and post-acute providers.
• Incorporate the needs of neurodevelopmental, behavioral health, and medically complex populations into care management practices.

• Partner with revenue cycle and clinical leaders to prevent medical necessity and authorization-related denials.
• Analyze denial trends, identify root causes, and implement corrective actions addressing documentation, timeliness, and workflow gaps.
• Coordinate clinical input into appeals and use findings to strengthen prospective denial prevention.
• Monitor length of stay, avoidable days, authorization timeliness, and other utilization measures to identify improvement opportunities.
• Develop and manage departmental budgets, staffing plans, and resource allocation.

• Ensure practices align with applicable CMS requirements, accreditation standards, payer requirements, and organizational policies.
• Establish system-wide dashboards and reporting to monitor clinical, operational, and financial performance.
• Lead audits and improvement initiatives related to utilization review, discharge planning, documentation, and care coordination.
• Present performance trends, risks, and action plans to executive and facility leadership.
• Balance efficiency and financial stewardship with patient advocacy, appropriate care, and safe discharge practices.

• Provide direction, coaching, and accountability for Case Management and UR leaders and teams.
• Oversee recruitment, onboarding, competency development, and ongoing education.
• Foster collaboration across clinical, operational, and revenue cycle teams to resolve barriers and improve performance.
• Build a culture of consistent execution, shared accountability, and continuous improvement.

• Bachelor of Science in Nursing (BSN) required.
• Master of Science in Nursing (MSN) required.

• Minimum seven years of progressive leadership experience in hospital case management, including direct oversight of both Case Management and Utilization Review.
• Multi-site leadership experience required.
• Demonstrated success implementing unified processes and performance standards across multiple facilities.
• Strong expertise in medical necessity review, utilization management, care coordination, discharge planning, denial prevention, and length-of-stay management.
• Demonstrated ability to translate clinical, operational, and financial data into measurable improvements.
• Experience collaborating with physicians, clinical leadership, operations, and revenue cycle teams.
• Knowledge of applicable CMS regulations, accreditation standards, and payer requirements.
• Experience serving neurodevelopmental, behavioral health, rehabilitation, and medically complex populations strongly preferred.

• Current, valid Texas Registered Nurse (RN) license required.
• Case management certification, such as ACM, CCM, CMGT, or equivalent, required within two years of hire if not currently held.

• Strategic foresight with the ability to turn organizational priorities into effective daily operations.
• Strong analytical, communication, change management, and interdisciplinary collaboration skills.
• Ability to establish accountability and lead improvements across multiple facilities.
• Proficiency with InterQual®, EHR systems, and healthcare performance reporting.
• Patient-centered judgment that balances clinical needs, compliance, operational efficiency, and responsible resource management.

• Lead the integration and advancement of Case Management and UR across a specialized health system.
• Partner with executive and clinical leaders to make a measurable impact on patient care and organizational performance.
• Support meaningful work serving patients with complex medical and behavioral needs.
• Join a mission-driven organization offering competitive compensation, comprehensive benefits, and professional growth opportunities.