Virginia Premier Health Plan, Inc.

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Case Manager III

Case Manager III

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Job Description


The Case Manager III focuses on high risk ABD members utilizing face to face nurse case manager visits integrated with a multidisciplinary team and the member’s primary care physicians in an effort to enhance quality and reduce medical utilization.


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.


  • Conducts a comprehensive assessment of the member’s health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the member and family or caregiver.
  • Plans with the member, family or caregiver, the PCP/provider, other health care providers, and the community to maximize health care responses, quality and cost-effective outcome
  • Facilitates communication and coordination between members of the health care team, involving the member in the decision-making prcoess in order to minimize fragmentation in the services. 
  • Educates the member, the family or caregiver, and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, case management , etc., so that timely and informed decisions can be made.
  • Empowers the member to problem solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes
  • Encourages the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case–by-case basis.
  • Assists the member in the safe transitioning of care to the next most appropriate level
  • Strives to promote member self-advocacy and self-determination
  • Acts as an advocate for a member’s health care needs
  • Participates in VPHP’s ongoing quality improvement process
  • Participates in continuing educational activities as appropriate
  • Participates in case management rounds/meetings
  • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)
  • Interviews members telephonically, in the physician’s office, home visits or in other facilities to provide initial and ongoing case management services.
  • Conducts regular discussions and updates with the member’s primary care physicians, other providers and members of the multidisciplinary health service team



  • Registered Nurse licensed in Virginia
  • BSN preferred
  • Certified Case Manager preferred


  • Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees.
  • PC literate with working knowledge of Microsoft Office and various computer software programs
  • Working knowledge of resource options, and experience in making appropriate referrals
  • Strong decision making skills, ability to handle multiple priorities
  • Regular local travel will be required


  • Minimum of 3 years clinical experience and/or current managed care experience
  • Experience working with low income and disadvantage populations
  • Utilization management experience and knowledge of community resources preferred.


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




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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