Lead Care Manager

Network Health Administrative Services, LLC; Menasha (WI); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Lead Care Manager to enhance care management programs. This role involves close collaboration with frontline staff and leadership, acting as a subject matter expert in Population Health documentation. The Lead Care Manager will conduct routine audits, assist in policy development, and ensure compliance with healthcare regulations. Ideal candidates will have a strong clinical background, excellent communication skills, and the ability to work both independently and as part of a team. If you're passionate about improving patient care and thrive in a dynamic environment, this opportunity is for you.

Qualifications

• 4+ years of clinical healthcare experience as an RN or Social Worker.
• Current registered nurse licensure or Social Worker license in Wisconsin.

Responsibilities

• Facilitates resolution of clinical care management issues.
• Maintains a member caseload and performs core care management duties.
• Performs monthly and quarterly case audits.

Skills

Communication Skills

Critical Thinking

Organizational Skills

Adaptability

Teamwork

Education

Bachelor of Science Degree in Nursing

Master’s Degree in Social Work

Job description

The Lead Care Manager works closely with front line department employees and leadership to be the first-line contact person for Care Management program inquiries. The Lead Care Manager acts as a subject matter expert for the Population Health documentation platform, performs routine case audits, and carries out Care Manager duties. Additionally, the incumbent will assist with process improvement and policy/procedure maintenance.

Job Responsibilities:

1. Demonstrates commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health.
2. Appropriately applies all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies.
3. Assists in developing and implementing policies, procedures, processes, materials, clinical guidelines, and documents for the care management program that comply with CMS, State of Wisconsin, NCQA, and other regulatory agencies. Supports communication and understanding of standards among team members and works with leadership to address gaps and improve processes.
4. Serves as the first-line contact to facilitate resolution of clinical care management issues.
5. Acts as a subject matter expert for the Population Health documentation platform.
6. Performs monthly and quarterly case audits.
7. Assists in monitoring care management metrics to measure effectiveness and value of the programs.
8. Maintains a member caseload and performs core care management duties, including screening candidates, completing assessments, developing care plans with prioritized goals, interventions, and timeframes; evaluating member needs; updating care plans; closing cases upon goal achievement; providing information to members, caregivers, and providers; evaluating and processing referrals; and advocating for members to ensure health needs are met.
9. Maintains current knowledge of State of Wisconsin, CMS, and NCQA case management standards and stays updated on best practices and new developments.
10. Performs other duties as assigned.

Job Skills:

• Strong oral and written communication skills, with the ability to listen mindfully, identify gaps, and ask appropriate questions.
• Strong critical thinking skills.
• Ability to organize work and space to ensure successful task completion within deadlines.
• Ability to adapt to new circumstances, information, and challenges in a fast-paced environment.
• Ability to work independently and as part of a team in a remote capacity.

Job Requirements:

• Bachelor of Science Degree in Nursing or Social Work required.
• Master’s degree in Social Work preferred.
• Minimum of four (4) years of clinical healthcare experience as an RN or Social Worker.
• Minimum of two (2) years experience with Medicare, Medicaid, commercial fully insured, and/or self-funded populations.
• Experience with Network Health processes is preferred.
• Current registered nurse licensure in Wisconsin or licensed in Wisconsin as a Social Worker (CSW, CAPSW, or LCSW).

Candidates must reside in Wisconsin. This position is eligible for remote work with reliable internet required.

We are proud to be an Equal Opportunity Employer, committed to maintaining a diverse workforce.