Company Description

Job Description

• Effectively managing day to day Health Plan Clinical Programs to enhance clinical efficiencies
• Identifying opportunities for increased outpatient vs. inpatient utilization
• Utilizing data provided to help in managing population health needs and implement population programs for Health Plan beneficiaries
• Executing case management for patients identified at highest risk for adverse event or exacerbation, having the ability to impact, with the goal of decreasing unnecessary emergency department visits/hospitalizations
• Overseeing an extended patient care team as assigned including but not limited to: Social Workers, Emergency Department Liaisons, Behavioral Health Liaisons, and Home Health Liaisons
• Overseeing smooth Transitional Care Management for all patients discharged from inpatient facilities ensuring various follow-ups and community services
• Ensuring Quality Measures are reviewed and addressed when applicable/appropriate
• Implementing and directing Health Plan Health Education Activities for beneficiaries, providers, and staff
• Participating in Care Coordination and Quality Committees, Primary Care Provider Meetings, and other meetings as required
• Monitoring corporate initiatives and strategies to achieve utilization of business and financial goals
• Managing the successful integration of ACO Programs into current operations to meet goals of stakeholders
• Maintaining collaborative relationships with business partners within the company and community
• Managing and executing organizational opportunities and implementing changes aligned with financial goals and strategies
• Managing departmental expectations including staff-related activities and performance improvement
• Prioritizing data, tasks, requirements, project management with expertise in departmental processes
• Representing for health plan audits and developing action plans to ensure compliance and incentive payouts
• Overseeing all projects, productivity, daily tasks, and PHM activities efficiently
• Ensuring access to EMR systems for department staff
• Monitoring staff maintenance of HIPPA regulations
• Communicating with health plan contacts, customer administrators, and client business managers for resolution of concerns
• Identifying and disseminating Health Plan announcements applicable to Case Management

Qualifications

• RN/BSN required
• 5 years of management experience
• 4 years clinical nursing experience
• At least 4 years of extensive experience in chronic care case management in outpatient setting
• Certification in case management preferred
• Must be able to work remotely and obtain state licensure in Illinois, Georgia, Pennsylvania, and Texas
• Must feel comfortable and confident leading a team of certified but unlicensed personnel and Registered Nurse case managers
• Ability to read, analyze, and interpret complex documents and respond effectively to sensitive inquiries or complaints

Additional Information

• We are Driven by Accountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
• Always Growing, Always Learning — staying curious and continuously improving inspires us to shape a better future for healthcare.
• With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
• At Guidehealth, Every Voice Matters — we believe our collective strength is rooted in the unique perspectives of each team member.
• And through Empathy in Action, we build stronger connections with those who count on us.
• This is what it means to be ALIVE with purpose. This is how we thrive — together — at Guidehealth.