RN Manager, Case Management

Virginia Premier Health Plan, Inc.; Richmond (VA); On-site; USD 70,000 - 90,000; Full time

Job summary

Virginia Premier Health Plan, Inc. is seeking an experienced leader for case management to supervise team operations and ensure compliance with policies. Responsibilities include managing clinical decisions, training staff, and improving processes.

The ideal candidate will have strong problem-solving skills, knowledge of community resources, and be a licensed Registered Nurse in Virginia. This role requires participation in ongoing education and community programs to address health needs across various age groups.

Qualifications

• Experience in case management in a managed care environment.
• Clinical nursing experience preferable.
• Experience with low income disadvantaged populations.

Responsibilities

• Lead and manage case management staff.
• Ensure compliance with policies and procedures.
• Identify trends for quality improvement.
• Maintain confidentiality of patient information.
• Participate in continuing education activities.

Skills

Problem solving

Patient assessment

Knowledge of community resources

Negotiation skills

Verbal communication

Written communication

Knowledge of ICD-9 and CPT4 coding

Six Sigma Lean methodology

Education

Registered Nurse licensed to practice nursing in Virginia

Job description

POSITION 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.

POSITION DUTIES AND 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 monitoring 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.

SPECIAL KNOWLEDGE AND/OR SKILLS

• Excellent problem solving skills
• Patient assessment skills
• 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 working knowledge of computers and word processing programs
• Ability to build and support successful work teams
• Possess knowledge of ICD-9 and CPT4 coding
• Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology

WORK BACKGROUND/EXPERIENCE

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

REQUIREMENTS

• Registered Nurse licensed to practice nursing in Virginia

PHYSICAL REQUIREMENTS

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

EOE