Care Management Program Manager

Triple-S Management Corp.; San Juan (PR); Presencial; USD 90.000 - 120.000; Jornada completa

Descripción de la vacante

Triple-S Management Corp. is seeking a Care Management leader to oversee operations, ensure compliance, and drive program quality for member health initiatives in Puerto Rico.

The role coordinates Health Risk Assessments, Care Plans, and interdisciplinary teams—partnering with internal departments to enhance service delivery. Ideal candidates hold a Bachelor’s in Health Education or Nursing, with 3–5 years in health insurance or care management; Master’s degree is preferred and licensure is

Formación

• Bachelor’s degree in Health Education or Nursing is required; Master’s degree preferred.
• Three to five years of related experience in health insurance or care management.
• Current/licensed credentials in health education, nursing, or health services administration are desirable.

Responsabilidades

• Oversee daily operations of the Care Management department ensuring regulatory, contractual, and quality compliance.
• Develop and execute departmental work plans aligned with corporate goals and governance.
• Ensure cost-effective, high-quality care through data-driven decision making and process improvements.
• Maintain reporting, statistics, and documentation for audits and program evaluation.
• Lead staff: hire, train, mentor, and evaluate performance to align with department objectives.

Conocimientos

Strategic leadership

Regulatory compliance

Clinical program execution

Data analysis

Staff management

Educación

Bachelor’s degree in Health Education or Nursing

Master’s degree preferred

Descripción del empleo

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

JOB SUMMARY

Responsible for the operations of the Care Management Program staff as well as oversight of the population programs under Triple S. Oversees the care coordination of all member needs including those with chronic clinical conditions. Responsible for coordination of health plan activities to the overall Care Management process, including member Health Risk Assessments, Individual Care Plans, Interdisciplinary Care Teams and other care activities, ensuring continue evaluation of members ‘care. It should work in close coordination with Delegated Entities, Internal Departments, Medical Director and other health professionals to ensure compliance and quality of services offered.

ESSENTIAL FUNCTIONS

Strategic Leadership & Financial Governance:
Oversee daily operations of the Care Management department to ensure regulatory, contractual, and quality compliance.
Assist in the development and execution of departmental work plans and strategic initiatives across the organization to ensure alignment with corporate goals and maintain Program governance.
Ensure operational efficiency through resource allocation, process improvement, and data-driven decision-making.
Regulatory Compliance:
Maintain comprehensive policies, procedures, analysis, and documentation required for internal and external audits, supporting corrective actions as needed.
Ensure adherence to all applicable standards and requirements established by CMS, ASES, URAC, and other regulatory bodies.
Monitor and evaluate key performance metrics, care goals, and quality outcomes, revising operational plans and internal documentation as needed to remain compliant.
Develop and implement performance interventions and process improvements (such as the PDSA cycles) based on utilization analysis and data driven decision – making.
Partner with Medical Directors, providers and internal divisions to monitor, support, and align integrated care delivery with corporate standards.
Clinical Program Execution:
Maintain accurate reporting, statistical analysis, and documentation for internal and external audits. Develop and implement projects aimed at improving cost-effectiveness, quality outcomes, and member satisfaction.
Participate in committees and initiatives across the organization to support strategic goals.
Assist in the development of annual work plans, program descriptions, and strategic initiatives.
Efficiency & Optimization:
Ensure overall operational efficiency through proper resources allocation, process improvement, and data – driven workflow decision – making.
Interview, hire, train, mentor, and evaluate direct reports, ensuring staff performance aligns with departmental goals.
Provide coaching, counseling, and recognition to promote engagement and productivity.
Manage workflow, delegate tasks, and monitor staff activities to ensure effective operations.
Communicate policies, procedures, program updates, and performance metrics to staff consistently to optimize system utility and compliance.

EDUCATION

• Bachelor's Degree in Health Education or Nursing

EXPERIENCE

• Bachelor’s Degree (master’s degree, preferred) in Health Education, Nursing Sciences, Health Services Administration or other health related areas.
  Three (3) to five (5) years of experience in a related area preferably in the Health Insurance Industry.
• Current/ valid license in Health Education, Nursing or Health Services Administration without restrictions, Case Management Certification, preferable.

COMPETENCIES

• Action Oriented
• Manages Ambiguity

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.