Manager, Case Management

Medica•Madison, WI

18h•$88,800 - $133,245•Hybrid

About The Position

The Manager, Case Management is responsible for the daily operations and performance of Medica’s Health Services Case Management team. The role provides overall direction to clinical staff and implements, evaluates, intervenes in, and improves programs for Medica’s commercial and government lines of business. Case management activities focus on comprehensive plans of care, collaborative interactions with members and providers, and purposeful direction of each case. The manager oversees case management and transition-of-care programs, coordinates with internal teams and vendor partners, supports population-specific care coordination and complex case management, and leads efforts involving end-of-life management, post-discharge transitional care, predictive modeling, proactive member identification, and specialty condition management. The role is also accountable for NCQA alignment, regulatory and accreditation compliance, program performance, staffing, reporting, and operational improvement. This is an office role requiring onsite work an average of three days per week. Candidates may be located near Medica’s offices in Minnetonka, Minnesota, or Madison, Wisconsin. The full salary grade is $88,800–$152,300, with a typical hiring range of $88,800–$133,245. The position may also be eligible for incentive compensation. Medica does not offer work visa sponsorship for this role; candidates must be legally authorized to work in the United States at the time of application.

Requirements

For the RN pathway: Associate’s or Bachelor’s degree in Nursing.
For the Social Work pathway: Master’s degree in Social Work.
At least 8 years of related work experience beyond the required degree.
Active, unrestricted RN license in the state of residence, or an active, unrestricted Independent or Advanced Practice Social Worker license in the state of residence.
Certified Case Manager (CCM) certification is preferred, or the ability and commitment to obtain it within two years of hire.

Nice To Haves

At least 5 years of managed care experience in health management; care management, utilization management, or disease management experience is strongly preferred.
At least 5 years of experience leading and/or managing professional staff, including staff development and performance management, is strongly preferred.
Experience leading case management programs.
Experience implementing regulations, legislation, rules or laws, and accreditation standards.
Experience with case management and utilization management tools.
Experience with data collection, development of assessment tools, and analysis of analytics and reporting.
Complex project management experience and a proven record of successful outcomes, including process-change implementation and contributions to strategic initiatives.

Responsibilities

Oversee and implement Case Management and Transition of Care Programs.
Collaborate with case management teams to integrate programs across Medica.
Track and evaluate productivity, program performance, and performance guarantees; develop program recommendations.
Collaborate with business segments and clinical leadership to support seamless operations and service.
Manage, supervise, and direct case management staff.
Serve as a case management subject matter expert for Medica, clients, and project teams.
Serve as a key clinical contact for resolving segment operational issues and implementing action plans.
Maintain communication among stakeholders and departments, including Customer Service, Claims Operations, Provider Services, Medical Directors, Pharmacy, and Account Management.
Oversee Interdisciplinary Team meetings and keep leaders informed about high-cost claimants and their health management.
Coordinate with Health Services teams, Utilization Management, Innovation, Pharmacy, Health Care Economics, vendors, and Medical Behavioral Health to support alignment and operational efficiency.
Develop and oversee customer and regulatory audit processes for the case management team.
Monitor case quality, including decision-making, documentation, and compliance with regulatory, accreditation, and policy or procedure changes.
Lead the case management team in alignment with Medica’s organizational direction and goals.
Ensure conformance to processes, policies, procedures, quality improvement activities, and customer requirements.
Collaborate on policies and procedures used in case management decision-making across Medica’s segments.
Deliver departmental dashboard reporting and facilitate team meetings and team-building activities.
Create a positive team climate by setting goals, achieving results, eliminating non-value-added activities, and recognizing good work.
Integrate team processes with Utilization Management, segment operations, pharmacy, MBH, Provider Services, Claims Operations, Account Management, and other departments.
Complete and ensure compliance with business policies and procedures; assess staffing and structure impacts from change and implement plans as needed.
Work with the Care Support Manager to assess work distribution and staffing ratios.
Maintain NCQA requirements and alignment, support regulatory and accreditation compliance, develop action plans, monitor audit results, and assess business-case recommendations.
Participate in customer, accreditation, and regulatory audits; implement applicable compliance obligations and ensure staff receive adequate compliance training.
Develop and maintain measurement and reporting tools, represent data, and provide feedback and recommendations to clinical management.
Work with departmental and cross-functional teams to implement identified opportunities while maintaining regulatory compliance.
Perform other duties as assigned.