JOB SUMMARY:

The Manager, Population Health and Case Management, leads the daily operations, implementation, and evaluation of CommunityCare’s Population Health Management (PHM) and Case Management programs. This position translates strategy into workflows that support proactive member identification, outreach, engagement, and coordinated care across assigned lines of business.

The Manager leads a multidisciplinary team, ensuring services address members’ medical, behavioral health, medication, and social needs. In partnership with the Director, this role strengthens staff accountability, monitors performance, supports regulatory and accreditation readiness, and advances member-centered care, improved health outcomes and access, and reduced avoidable utilization.

KEY RESPONSIBILITIES:

• Lead the implementation, operations, and continuous improvement of Population Health Management (PHM) and Case Management programs, including risk-based outreach, chronic condition support, transitions of care, preventive care, and social needs interventions.
• Translate departmental strategy into operational plans, workflows, staffing responsibilities, performance expectations, and standardized processes for member identification, referral, assessment, enrollment, care planning, follow-up, reassessment, and program discharge.
• Lead daily operations of the multidisciplinary PHM team by managing workloads and caseloads, monitoring productivity and documentation quality, conducting team meetings and performance reviews, and providing coaching, onboarding, training, and staff development.
• Oversee risk stratification, member engagement, assessments, individualized care plans, care coordination, and transitions of care to support members’ medical, behavioral health, medication, functional, and social needs.
• Coordinate multidisciplinary services across nursing, pharmacy, social work, and administrative support, and collaborate with internal departments, providers, caregivers, and community organizations to promote continuity of care and avoid duplication of services.
• Oversee implementation of assigned Dual Eligible Special Needs Plan (D-SNP) Model of Care requirements, including health risk assessments, individualized care plans, interdisciplinary care team activities, member and caregiver engagement, provider communication, staff training, and performance monitoring.
• Develop and maintain policies, procedures, documentation standards, training materials, and workflows that support effective program operations and compliance with CMS requirements, URAC standards, contractual obligations, and organizational policies.
• Monitor program performance, documentation, outreach, care coordination, and corrective actions to identify gaps, address operational barriers, and support continuous improvement.
• Support internal and external audits, regulatory reviews, and accreditation activities by maintaining required documentation and evidence of program implementation, staff training, monitoring, and improvement activities.
• Partner with the Director to address significant clinical, staffing, system, compliance, and operational concerns and implement corrective actions as needed.
• Maintain member confidentiality and promote appropriate handling of protected health information (PHI).
• Perform other job-related duties as required or assigned.

QUALIFICATIONS:

• Demonstrated knowledge of predictive analytics, health equity, social drivers of health, and program outcome evaluation.
• Demonstrated knowledge of risk stratification, member engagement, individualized care planning, and multidisciplinary care coordination.
• Ability to analyze performance data, identify gaps and trends, and implement improvements to enhance program outcomes.
• Knowledge of health plan operations and applicable regulatory, accreditation, and contractual requirements.
• Ability to develop, implement, and improve clinical workflows, policies, procedures, and operational programs.
• Ability to translate strategic priorities into effective and sustainable daily operations.
• Strong leadership, coaching, delegation, and accountability skills.
• Strong written, verbal, presentation, and documentation skills.
• Ability to manage competing priorities, resolve operational barriers, and effectively lead change.
• Ability to establish and maintain productive relationships with members, staff, providers, and community partners.
• Sound judgment in assessing clinical escalation needs, professional scope of practice, and operational risk.
• Proficiency with care management systems, electronic health records and documentation, reporting tools, and Microsoft Office applications.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Bachelor’s degree in nursing, public health, healthcare administration, social work, or a related field; Master’s degree preferred.
• A minimum of five years of progressively responsible experience in population health, case management, care coordination, managed care, or related healthcare operations.
• A minimum of three years of supervisory or management experience, including staff development and performance oversight.
• Current, active, unrestrictive license to practice as a Registered Nurse, Certified Case Manager (CCM), or licensed Social Worker in the State of Oklahoma.
• Experience supporting CMS audits, URAC accreditation, and corrective action plans preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin.