Manager, Case Management

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Manager, Case Management is responsible for daily operations and the performance of the Health Services Case Management team. This includes:

• Relationship building within Medica and its vendor partners to prioritize, integrate and coordinate interventions for population segments based on medical, behavioral and social needs
• Relationship building with provider care teams as accountable partners facilitating member self-care management
• Adoption of transformational interventions and case management models for conditions and populations driving medical expense trend
• Population specific care coordination
• Population specific complex case management
• EOL management
• Transitional care management (post-discharge)
• NCQA compliance
• Predictive modeling and proactive member identification
• Specialty medical condition management (i.e., transplant, pregnancy)

The Manager, Case Management provides overall direction to clinical staff and is responsible for the implementation, evaluation, intervention and improvement of programs delivered for the Medica commercial and government lines of business. The case management activities in the team are engineered to deliver process oriented outcomes, through focus on a comprehensive established plan of care, collaborative interactions with the member and provider, and the Medica Case Manager assuming assertive, purposeful direction of the case. Performs other duties as assigned.

Key Accountabilities

Case Management and Transition of Care Program Operations

• Responsible for oversight and implementation of Case Management and Transition of Care Programs.
• Collaborates with Medica Case Management teams to assure integration across all Case Management Programs at Medica.
• Tracks and evaluates productivity, program performance and the performance guarantees. Develops program recommendations.
• Collaborates closely with Medica’s business segments and clinical leadership to ensure seamless operations and service.
• Provides management, supervision, and direction to case management staff.
• Acts as a subject matter expert for case management for Medica, our clients and in project teams.
• Serves as key clinical contact in the resolution of segment operational issues and implementation of action plans.
• Maintains communication between key stakeholders and departments such as Customer Service, Claims Operations, Provider Services, Medical Directors, Pharmacy, and Account Management.
• Provides oversight of Interdisciplinary Team meetings and keeps leaders informed of high cost claimants and their health management.
• Collaborates closely with other areas within Health Services; Utilization Management, Innovation, Pharmacy and Health Care Economics to ensure collaboration and alignment, as well as operational linkages and efficiencies, including vendors and Medical Behavior Health.
• Develops and oversees process of customer and regulatory audits for the case management team.
• Monitors case quality to ensure competence in case management and care support decision-making, documentation and compliance with regulatory, accreditation and policy/procedure changes.
• Provides leadership to the case management team in the context of Medica’s direction and goals as an organization.

Maintain efficient departmental operational systems and processes

• Ensures conformance to processes, policies and procedures, quality improvement activities and customer requirements.
• Collaborates on policies and procedures used in decision making by case management staff across Medica’s segments.
• Delivers reporting for departmental dashboard.
• Facilitates team meetings and team building activities.
• Creates positive team climate by setting individual and team goals and achieving results, eliminating non-value added activities, and recognizing and rewarding good work.
• Integrates team processes with those of Utilization Management, segment operations, pharmacy, MBH, and other departments (i.e., Provider Services, Claims Operations and Account Management departments).
• Completes and ensures compliance with business policies/ procedures.
• Assesses staffing/structure impacts due to change, and implements plans as necessary.
• Works with Care Support Manager to assess work distribution and staffing ratios.

Regulatory and Accreditation Compliance: assessment, monitoring and implementation

• Oversees and maintains NCQA requirements and alignment.
• Assures reasonable compliance with regulatory/accreditation standards and implements departmental action plans as necessary.
• Develops and implements compliance with department policies and procedures.
• Monitors audit results, assesses business case recommendations.
• Participates in customer audits, and audits for accreditation and regulatory purposes.
• Assesses and implements compliance obligations as required by government and accreditation entities.
• Ensures adequate staff training regarding regulatory and accreditation compliance

Monitor, track and report trends to facilitate benefit design, medical policy decisions and improve operational efficiencies

• Develops and maintains measurement reporting tools and reports and provides representation of data.
• Provides feedback between team and clinical management regarding reports and recommendations.
• Responsible to work with departmental and cross-functional teams to implement above noted opportunities, insuring all regulatory requirements maintained.

Registered Nurse (RN) Required Qualifications

• Associate's or Bachelor's degree in Nursing
• 8+ years of related work experience beyond degree

Social Work (SW) Required Qualifications

• Master's degree in Social Work
• 8+ years of related work experience beyond degree

Required Certifications/Licensure

• Active, unrestricted RN License in the state of residence or active, unrestricted Independent or Advanced Practice Social Worker license in the state of residence
• Certified Case Manager (CCM) preferred, or ability and commitment to obtain within two years of hire

Preferred Qualifications

• Minimum of 5 years of managed care experience in health management; care management, utilization management, disease management strongly preferred.
• Minimum of 5 years experience with leading and/or managing professional staff including experience with staff development and performance management strongly preferred.
• Experience with leading case management programs.
• Experience with implementing regulations, legislation, rules and/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.
• Experience with complex project management required; proven track record of successful outcomes (implementation of process change, etc.) and contribution toward strategic initiatives.

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN or Madison, WI.

The full salary grade for this position is $88,800 - $152,300. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $88,800 - $133,245. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.