• Case Manager - Clinical Programs (Program Coordination)

    Job Locations US-VA-Glen Allen
    Job ID
  • Overview

    The Clinical Programs Case Manager, is responsible for the day-to-day administrative and operational oversight of the clinical case management programs. Primary responsibility is day to day coordination of patient care, communication, of patient data to appropriate personnel, receiving initial referral information from multiple Utilization Monitoring reports for both Medicaid (PUMS, multiple clinical programs) and Medicare (OMS/Patient Safety Programs).


    • Maintains a current knowledge base of Clinical programs, policy and procedures. Regularly reviews and reacts to policy updates and departmental procedures.
    • Oversees and ensures timely resolution of Virginia Premier pharmacy clinical program issues, including care coordination, care management, disease management and other related pharmacy care issues.
    • Prioritizes Virginia Premier pharmacy care coordination as appropriate per DMAS PUMS requirements. (Patient Utilization Management & Safety)
    • Manages the day-to-day plan contacts and reads, works and maintains all CMS patient safety analysis reports. In addition works and maintains electronic and hard copies of Patient Safety Analyses notebooks.
    • Interfaces and manages operational issues with Vital functional areas and ensures timely delivery of pharmacy monthly/quarterly reports
    • Supports Virginia Premier Case Management activities by facilitating all pharmacy driven/related services and clinical programs.
    • Read, work and maintain all CMS patient safety analysis reports, and user guides related to:
      • Patient Safety Analysis-Overutilization Monitoring system
      • Patient Safety Analysis-Patient Safety Edits
    • Maintains working knowledge of member case, manages and coordinates care and referrals to pertinent staff (Pharmacy, Medical) in a timely manner.
    • Work with the pharmacy clinical coordinators who help resolve any issues between Virginia Premier and Pharmacy Benefit Manager.
    • Serve as an internal resource for interfacing with other internal departments personnel to resolve pharmacy clinical program issues.
    • Assist the Pharmacy Director with clinical reporting and member and provider outreach for medication management.



    • BA/BS degree preferred
    • RN License to practice in the Commonwealth of VA   OR LCSW
      CPhT designation (PTCB certification program) preferred


    • Previous clinical program experience related to case management 
    • Proficient personal computer, MS Office, Excel and project coordination skills


    • Minimum 1 year Nurse Case Management operations experience
    • Minimum 1 year Managed Care experience 


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


    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.  


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


    About Us

    Virginia Premier 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. 


    Equal Opportunity Employer 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.


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