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, with the goal of decreasing unnecessary emergency department visits/hospitalizations
• Overseeing an extended patient care team as assigned including 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 follow-ups with Primary Care Provider, DME and Home Health Services, Specialist appointments, and community resources/social 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
• Maintaining collaborative relationships with business partners within the company and community
• Managing organizational opportunities and implementing changes aligned with corporate financial goals and strategic endeavors
• Managing departmental expectations including staff hiring, orientation, auditing, reviews, time management, motivation, and performance improvement
• Prioritizing data, tasks, and requirements; project management within departmental processes
• Representing the company for health plan audits and developing action plans to ensure compliance and incentive payouts
• Overseeing all projects, productivity, daily tasks, and PHM activities in an organized manner
• Ensuring access to EMR systems for department staff
• Monitoring staff compliance with HIPPA regulations
• Communicating with health plan contacts, customer Administrators, and Client Business Managers to resolve any concerns
• Identifying and disseminating applicable Health Plan announcements related to Case Management

Qualifications

• RN/BSN required
• 5 years of management experience
• 4 years clinical nursing experience
• At least 4 years extensive experience in chronic care case management in an outpatient setting
• Certification in case management preferred
• Must be able to work remotely and obtain state licensure in Illinois, Georgia, Pennsylvania, and Texas
• Ability to lead 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

• Driven by Accountability—grounded in transparency, reliability, and integrity.
• Always Growing, Always Learning—staying curious and continuously improving.
• Collaborative Innovation—solving problems creatively to improve experiences.
• Every Voice Matters—valuing unique perspectives of each team member.
• Empathy in Action—building stronger connections.