Virginia Premier Health Plan, Inc.

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Manager, Case Management

Manager, Case Management

Job Locations 
US-VA-Roanoke
Job ID 
2017-4090

Job Description

Overview

Responsible for leadership and management of case management staff, including operational decisions, daily clinical decisions, process improvement, staff development, and compliance with VPHP policies and procedures.

Medical Management

Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

Responsibilities

  • Supervises Case/Care Management (CM), Social Work (SW) and other support staff according to VPHP’s policy and procedures to assure that CM reviews and SW activities are accurate, consistent, and performed in a timely manner
  • Assists with the development of CM and SW staff onboarding and training programs.
  • Coaches staff and supports healthy team dynamics.
  • Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor case management activities.
  • Review specialized reports to identify trends and opportunities for improvement to enhance relationships with the provider network and service to members.
  • Ensure requirements for auditing CM decisions, documentation and quality are being met.
  • Assists Director of CM with ongoing Quality Improvement Program by assisting with various quality review tasks such as collecting and analyzing data as outlined in the program.
  • Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department.
  • Maintains confidentiality of patient information, and VPHP proprietary operational information.
  • Maintains current knowledge of VPHP policies and procedures.
  • Participates in continuing education activities as appropriate.
  • Participates in community programs (which may occur outside of normal business hours).
  • This position provides services and demonstrates the knowledge and ability to meet the specific needs of the following age groups: All Infant   Adult  Child Geriatric
  • Other duties as assigned.

Qualifications

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Excellent problem solving skills
  • Patient assessment skills
  • Knowledge of Medicare and Medicaid regulations
  • Knowledge of community resources and vendor options, and experience in making appropriate referrals
  • Ability to negotiate with providers and vendors
  • Demonstrates excellent verbal and written communications
  • Demonstrates proficiency in Microsoft Office applications
  • Ability to build and support successful work teams
  • Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology 

WORK BACKGROUND/EXPERIENCE

  • Case management experience, preferably in a managed care environment
  • Management experience in a managed care environment preferred
  • Experience in clinical nursing
  • Experience working with low income disadvantaged populations.

REQUIREMENTS:

  • Registered Nurse licensed to practice nursing in Virginia
  • Bachelor’s degree
  • Certified Case Manager (CCM), preferred

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us

 

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

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