Job Description: Case Management Lead

Position Overview

Become a part of our caring community and help us put health first. This role reports directly to the Director, Case Management and supports the strategic priorities for Clinical Operations, Medical & Behavioral Health and Humana Government Business (HGB). The Case Management Lead leads clinical functions specifically related to Case Management programs and support for beneficiaries in the TRICARE East region.

Responsibilities

• Coordinates, assesses, and monitors the coordination of Case Management program activities, ensuring maximum quality, benefits, and effectiveness for beneficiaries.
• Monitors Case Management team workload and engagement performance.
• Coaches Case Management team as needed to achieve Government performance standards.
• Keeps the Director, Case Management apprised of progress and issues within their area of responsibility.
• Performs all duties within the scope of their role requirements.
• Coordinates as needed with members of the Case Management team on cases with support needs.
• Ensures regulatory compliance by aligning care management policies, procedures, and processes to maintain TRICARE contractual standards, improve clinical outcomes, and support associate engagement.
• Collects and analyzes individual and team data to determine operational efficiency and effectiveness.
• Responsible for hiring, coaching, leading, and managing performance for up to 16 associates.

KEY ACCOUNTABILITIES

• Lead and Develop Direct Reports: Articulate strategic, operational, and tactical goals to focus on consistent execution of Care Management processes and ensure teams meet their goals. Escalate critical challenges and/or issues to the reporting leader. Develop action plans to improve operational results.
• Operational Goal Development and Implementation: Ensure the development and implementation of operational goals, training programs, policies, procedures, and quality improvement projects related to Care Management programs and support. Identify training needs, lead, develop, and participate in staff training.
• Monitoring and Performance Improvement: Ensure the implementation of monitoring systems and measurements related to Care Management program support initiatives to maintain focus on performance goals and standards, quality, and compliance measures. Develop action plans to improve results.
• Government and Contractual Compliance: Ensure compliance with Government and contractual requirements related to Care Management program support and initiatives by maintaining a working relationship with the government customer and other HGB departments.
• Beneficiary Coordination and Quality: Interface with quality management and clinical operations programs, ensuring beneficiary coordination of care.
• Accreditation and Certification: Ensure processes and procedures are in place and applied consistently to maintain appropriate accreditation and certifications related to Care Management programs and support.
• Process Optimization: Perform team analysis, identify insights, process gaps, variation, and non-value-added tasks. Work closely with leaders to implement strategies focused on maximizing performance and health outcomes. Provide input for process validation to re-think routine, ensure simplicity, and streamline health solutions.
• Special Projects: Perform special projects as assigned by the Clinical Operations Leadership.

Use your skills to make an impact.

Required Qualifications

• Our Department of Defense Contract requires U.S. citizenship for this position.
• Must successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services).
• HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
• Current valid and unrestricted Registered Nurse (RN) license.
• Certified Case Manager (CCM).
• 5 years of healthcare supervisory/management experience, including regulatory compliance experience.
• Experience in healthcare operations with stringent performance and government compliance requirements.

Preferred Qualifications

• 1 - 3 years of case management leadership experience.
• Previous success in project and program management.
• BSN.
• TRICARE experience.

Employment Type

• Full time

Salary

• Not Specified

Location Type

• Not Specified