Manager, Case Management

Position Location: 100% remote

Responsibilities

• Strategic Program Leadership and Transformation:
  • Provide visionary leadership and mentorship to the Case Management Team, fostering a culture of excellence and continuous improvement.
  • Lead program strategy, planning, implementation, and ongoing optimization to ensure Case Management programs meet organizational, clinical, quality, and accreditation goals.
  • Champion innovation, transformation, and change management initiatives that improve operational effectiveness, member outcomes, staff engagement, adoption, and program scalability.
• Supervision and Team Management:
  • Provide supervision and deliver comprehensive training, resources, and mentoring to ensure team adherence to Case Management standards per URAC.
  • Manage staff performance, communicate updates about organizational processes and changes affecting case management staff.
  • Provide training opportunities for continuing education and development, and current resources for case management staff to maintain knowledge, skills, and competencies.
  • Act as a resource for staff during the case management process.
  • Provide leadership, mentorship, and direction to Case Management Supervisors and the team to achieve program goals.
  • Manage and participate in interviewing, recruiting, and overseeing new hire processes and employee evaluation processes.
  • Evaluate effectiveness of training, coaching, and team retention strategies.
  • Maintain and oversee time and attendance for designated employees, as needed.
• Program Development and Compliance:
  • Develop, maintain, and communicate Case Management Policies and Procedures tailored to each program, with ongoing monitoring to ensure staff compliance.
  • Oversee and ensure consistency in program delivery for Case Management orientation and training plans, across all teams.
  • Participate in Quality Management program and Accreditation adherence:
    • Member of the Quality Management Committee (QMC).
    • Lead quality management initiatives as an active member of the QMC.
    • Act as a liaison between the Quality Management Committee and the employees.
  • Collaborate with Medical Management's Quality Management team to submit reports on policies and procedures requested for quality initiatives and applicable URAC standards and reporting measures.
  • Implement training and measure outcomes pertaining to quality as it relates to the case management activities.
  • Propose policy and procedure (P&P) changes to the Medical Management leaders and the Quality Management Committee to enhance program efficiency and quality.
• Quality Assurance and Continuous Improvement:
  • Oversee Quality Assurance review processes, ensuring high standards of service delivery within the team.
  • Manage new hire and employee Quality Assurance and evaluation processes.
  • Track and respond to internal and external feedback regarding Case Management services and employees, ensuring continuous improvement.
• Program Innovation and Best Practices:
  • Continuously research and implement industry best practices to drive innovation and excellence in the Case Management program.
  • Develop, monitor, and evaluate key program metrics, dashboards, scorecards, and performance trends to support program accountability, best-in-class delivery, and measurable outcomes for members and clients.
  • Lead cross-functional projects with Medical Management, Quality, Operations, Account Management, Compliance, and data/technology partners to advance program priorities and outcomes.
  • Apply project management principles to plan, execute, monitor, and sustain program initiatives, including timelines, deliverables, stakeholder engagement, risks, dependencies, communication plans, and outcomes.
  • Use data, reporting, root cause analysis, and trend analysis to identify opportunities, evaluate program performance, inform improvement plans, and drive measurable improvements.
• Accreditation and Compliance:
  • Lead all Accreditation processes, standards, and requirements within the Case Management programs.
  • Own Case Management URAC accreditation, ensuring proper auditing, processes, policies, and procedures are adhered to.
  • Responsible for reaccreditation processes for Case Management.
  • Lead the team and implement systems and processes that drive continuous quality improvement activities and accreditation requirements.
  • Ensure compliance with Imagine360 Policies and Procedures, internal Medical Management Policies, Department of Labor, ERISA, and HIPAA regulations.
• Stakeholder Collaboration and Communication:
  • Collaborate with Medical Management Account Management to provide reports and updates to Relationship Managers and clients.
  • Communicate effectively with brokers, vendors, Relationship Managers, HR representatives, and stop-loss providers, maintaining compliance with HIPAA.
• Monitoring and Other Duties:
  • Review, audit, and verify monthly billing hours from Case Management teams.
  • Complete annual HIPAA training and adhere to HIPAA/PHI guidelines.
  • Perform other duties and projects as assigned.
• Areas of Responsibility Scope of Practice:

  In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to:

  • Evaluating clinical data.
  • Assessment and evaluation of the acquired clinical data to assess the appropriateness of treatment based on Medical Management clinical guidelines.
  • Coordination of treatment plans, interventions, and outcome measurement.
  • Rationale for the effects of medication and treatments.
  • Provide patient education and educational resources.
  • Accurately report:
    • Administration of medication and treatments.
    • Client response.
    • Contact with other health care team members.
  • Respect the client's right to privacy by protecting confidential information.
  • Promote and participate in education and counseling to a participant based on health needs.
  • Clarify any treatment believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.
• The Manager, Case Management will have knowledge and practice the core components of Case Management that include:
  • Case Management Concepts.
  • Principles of Practice.
  • Healthcare Management & Delivery.
  • Healthcare Reimbursement.
  • Professional Development & Advancement.
  • Quality and Outcomes Evaluation and Measurement.
  • Accreditation.
  • Ethical, Legal and Practice Standards.

Requirements

• Required Education: A bachelor's degree in nursing from an accredited school of nursing, or years of experience in lieu of degree will be considered.
• Required Experience:
  • 5+ years' experience in Case Management or related field.
  • 3+ years' management experience in Case Management or a health-related field, experience leading teams of RNs or other licensed employees.
  • 3+ years' experience working in a URAC accredited Case Management program.
  • Experience leading teams of Supervisors, and proven success in achieving program goals.
  • Experience leading program or project initiatives, including planning, implementation, stakeholder coordination, change management, communication planning, risk management, and outcome measurement.
  • Experience using data, analytics, dashboards, scorecards, audit results, quality outcomes, and performance metrics to assess program effectiveness and inform operational or strategic decisions.
• Preferred Experience:
  • Experience leading clinical program transformation, process improvement, or operational redesign initiatives.
  • Experience developing or using dashboards, scorecards, reporting tools, or analytics to monitor program performance and outcomes.
  • Project management, Lean Six Sigma, change management, or process improvement experience preferred.
  • Experience supporting accreditation readiness, quality improvement initiatives, corrective action planning, or regulatory response activities preferred.

Skills and Abilities

• Demonstrated success motivating and engaging employees to achieve business and clinical program successes.
• Strong program leadership skills with the ability to align teams, resources, priorities, and stakeholders to achieve measurable program goals.
• Demonstrated ability to manage programs and projects, including timelines, deliverables, communication plans, risks, dependencies, stakeholder engagement, and adoption planning.
• Data-driven and analytical mindset with the ability to interpret trends, perform root cause analysis, evaluate outcomes, and translate insights into actionable improvement plans.
• Ability to identify, recommend, communicate, and lead innovation and transformation opportunities that improve processes, quality, efficiency, adoption, and member-centered outcomes.
• Vast knowledge of and direct experience with participating in the process for national accreditation requirements (i.e., URAC, NCQA).
• Ability to maintain a high level of accuracy and attention to detail to perform each essential duty satisfactorily.
• Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals.
• Ability to write routine reports and correspondence.
• Ability to communicate effectively with other employees, Brokers, clients, vendors, and customers.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
• Ability to apply concepts of basic mathematics and fundamental accounting principles.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
• Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations.
• Basic knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software.

Licenses or Certification

• Current, active, and unrestricted compact Registered Nurse license.
• Must maintain CEUs as required by the State Board of Nursing.
• Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
• Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.

Benefits

• Multiple Health plan options.
• Company paid employee premiums for disability and life insurance.
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