Manager, Case Management

Job Summary:

The Manager of Case Management provides leadership and oversight for Case Management staff of 60, programs and services for large Insurance provider. This position develops strategy and implements case management programs that meet strategic goals, aid in containing medical cost trends, and contribute to attracting and retaining profitable membership.  The manager is responsible for establishing and maintaining a system that evaluates the quality of member care and  program effectiveness.

Responsibilities:

1. Manages and coordinates the delivery of case management programs and services including:

•           Collaborating with Medical Staff to ensure clinical appropriateness of programs and clinical effectiveness measures; and

•           Coordinating program activities across Care Management departments, with Sales and Marketing and Claims Operations.

2. Assures development, implementation and maintenance of:

•           Case management procedures and policies;

•           Audit processes across Care Management functions to ensure quality performance and identify training opportunities;

•           Quality improvement activities; and

•           URAC ‘readiness preparation’ or other regulatory standards.

3. Assures compliance and reporting of ROI or other performance guarantees to senior leadership; proactively develop and monitor corrective action plans when needed.

4. Represents organization as the primary representative for case management to internal and external audiences as needed, including employers, State or regulatory authorities (URAC).

5. Assists in preparing market specific tools for Sales staff, Broker communications or other appropriate means serving as the clinical subject matter expert; presents program materials to employer groups, brokers, or external audiences as needed.

6. Participates in State/National Case Management workgroups, including BCBSA, URAC, and Consortium.

7. Attracts, retains, and motivates staff. Monitors associate performance, and provides timely feedback and coaching to associates on a regular basis to ensure continuous development to meet current and future needs of the business.

Minimum Qualifications:

1.         Bachelor’s Degree in Nursing or health related field or equivalent work experience.

2.         Current State Registered Nurse License.

3.         Have or obtain Certified Case Manager certification (CCM) or related certification within 36 months from date of hire.

4.         5 years management experience.

5.         5 years case management or related health care experience.

6.         Extensive human relations skills, ability to influence people against the odds, and ability to gain work team's trust, inspiring willingness to work toward company goals.

7.         Proven ability to lead, motivate and develop staff to meet business and organizational goals.

8.         Excellent verbal and written communication skills.

9.         Proven ability to negotiate positively and diplomatically in stressful situations.

10.       Ability to take initiative and demonstrate independent decision making for difficult and complex issues.

11.       Successful time management and organizational skills; experience in managing multiple projects concurrently in multiple locations or work units.

12.       Proven creditability as a change agent who effectively coaches and leads team members in a rapidly changing environment.

Additional Qualifications Preferred:

1.         Master’s Degree in a health related field.

2.         Project management experience.

3.         Experience with NCQA, URAC, or accreditation review processes.

4.         Experience working in the health plan industry.