Manager, case management

Imagine360 is seeking a Manager, Case Management to join the team! The Manager, Case Management will utilize education, clinical expertise, management experience, and a strong program leadership approach to lead the Case Management service area of the Medical Management department. The Manager, Case Management, is pivotal in ensuring the delivery of high-quality case management services while driving excellence in program outcomes through effective program and project management, data-informed decision-making, innovation, and transformation. The Manager of Case Management is expected to possess strong leadership skills, clinical expertise, an analytical mindset, and a commitment to improving patient care through effective management and collaboration, while maintaining compliance with the Registered Nurse Scope of Practice.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Strategic Program Leadership and Transformation: Provide visionary leadership and mentorship to the Case Management Team, fostering a culture of excellence and continuous improvement. Lead program strategy, planning, implementation, and ongoing optimization to ensure Case Management programs meet organizational, clinical, quality, and accreditation goals. Champion innovation, transformation, and change management initiatives that improve operational effectiveness, member outcomes, staff engagement, adoption, and program scalability.
• Supervision and Team Management: Provide supervision and deliver comprehensive training, resources, and mentoring to ensure team adherence to Case Management standards per URAC. Managing staff performance. Communicating updates about organizational process and changes affecting case management staff. Providing training opportunities for continuing education and development. Providing current resources for case management staff to maintain knowledge, skills and competencies for their role. Acting as a resource for staff during the case management process. Leadership, mentorship, and direction to Case Management Supervisors and the team to achieve program goals. Manage and participate in interviewing, recruiting, and overseeing new hire processes and employee evaluation processes. Evaluating effectiveness of training, coaching, and team retention strategies. Maintain and oversee time and attendance for designated employees, as needed.
• Program Development and Compliance: Develop, maintain, and communicate Case Management Policies and Procedures tailored to each program, with ongoing monitoring to ensure staff compliance. Oversee and ensure consistency in program delivery for Case Management orientation and training plans, across all teams. Participates in Quality Management program and Accreditation adherence in the following ways: Member of the Quality Management Committee (QMC). Leads quality management initiatives as an active member of the QMC. Is a liaison between the Quality Management Committee and the employees. Collaborate with Medical Management's Quality Management team to submit reports on policies and procedures requested for quality initiatives and applicable URAC standards and reporting measures. Implements training and measures outcomes pertaining to quality as it relates to the case management activities. Proposes policy and procedure (P&P) changes to the Medical Management leaders and the Quality Management Committee to enhance program efficiency and quality.
• Quality Assurance and Continuous Improvement: Oversees Quality Assurance review processes, ensuring high standards of service delivery within the team. Manage new hire and employee Quality Assurance and evaluation processes. Track and respond to internal and external feedback regarding Case Management services and employees, ensuring continuous improvement.
• Program Innovation and Best Practices: Continuous research and implementation of industry best practices to drive innovation and excellence in the Case Management program. Develop, monitor, and evaluate key program metrics, dashboards, scorecards, and performance trends to support program accountability, best-in-class delivery, and measurable outcomes for members and clients. Lead cross-functional projects with Medical Management, Quality, Operations, Account Management, Compliance, and data/technology partners to advance program priorities and outcomes. Apply project management principles to plan, execute, monitor, and sustain program initiatives, including timelines, deliverables, stakeholder engagement, risks, dependencies, communication plans, and outcomes. Use data, reporting, root cause analysis, and trend analysis to identify opportunities, evaluate program performance, inform improvement plans, and drive measurable improvements.
• Accreditation and Compliance: Responsible for leading all Accreditation processes, standards, and requirements within the Case Management programs. Own Case Management URAC accreditation, ensuring proper auditing, processes, policies, and procedures are adhered to. Responsible for reaccreditation processes for Case Management. Lead the team and implement systems and processes that drive continuous quality improvement activities and accreditation requirements. Ensure compliance with imagine360 Policies and Procedures, internal Medical Management Policies, Department of Labor, ERISA, and HIPAA regulations.
• Stakeholder Collaboration and Communication: Collaborate with Medical Management Account Management to provide reports and updates to Relationship Managers and clients. Communicate effectively with brokers, vendors, Relationship Managers, HR representatives, and stop-loss providers, maintaining compliance with HIPAA.
• Monitoring and Other Duties: Review, audit, and verify monthly billing hours from Case Management teams. Complete annual HIPAA training and adhere to HIPAA/PHI guidelines. Perform other duties and projects as assigned.

Areas of Responsibility Scope of Practice: In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to: Evaluating clinical data. Assessment and evaluation of the acquired clinical date to assess the appropriateness of treatment based on Medical Management clinical guidelines. Coordination of treatment plans, interventions, and outcome measurement. Rationale for the effects of medication and treatments. Provide patient education and educational resources. Accurately report: Administration of medication and treatments. Client response. Contact with other health care team members. Respect the client's right to privacy by protecting confidential information. Promote and participate in education and counseling to a participant based on health needs. Clarify any treatment believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.

The Manager, Case Management will have knowledge and practice the core components of Case Management that include: Case Management Concepts, Principles of Practice, HealthCare Management & Delivery, Healthcare Reimbursement, Professional Development & Advancement, Quality and Outcomes Evaluation and Measurement, Accreditation, Ethical, Legal and Practice Standards.

Education and Experience:

Required Education: A bachelor's degree in nursing from an accredited school of nursing, or years of experience in lieu of degree will be considered.

Required Experience: 5+ years' experience in Case Management or related field. 3+ years' management experience in Case Management or a health-related field, experience leading teams of RNs or other licensed employees. 3+ years' experience working in a URAC accredited Case Management program. Experience leading teams of Supervisors, and proven success in achieving program goals. Experience leading program or project initiatives, including planning, implementation, stakeholder coordination, change management, communication planning, risk management, and outcome measurement. Experience using data, analytics, dashboards, scorecards, audit results, quality outcomes, and performance metrics to assess program effectiveness and inform operational or strategic decisions.

Preferred Experience: Experience leading clinical program transformation, process improvement, or operational redesign initiatives. Experience developing or using dashboards, scorecards, reporting tools, or analytics to monitor program performance and outcomes. Project management, Lean Six Sigma, change management, or process improvement experience preferred. Experience supporting accreditation readiness, quality improvement initiatives, corrective action planning, or regulatory response activities preferred.

Skills and Abilities: Demonstrated success motivating and engaging employees to achieve business and clinical program successes. Strong program leadership skills with the ability to align teams, resources, priorities, and stakeholders to achieve measurable program goals. Demonstrated ability to manage programs and projects, including timelines, deliverables, communication plans, risks, dependencies, stakeholder engagement, and adoption planning. Data-driven and analytical mindset with the ability to interpret trends, perform root cause analysis, evaluate outcomes, and translate insights into actionable improvement plans. Ability to identify, recommend, communicate, and lead innovation and transformation opportunities that improve processes, quality, efficiency, adoption, and member-centered outcomes. Vast knowledge of and direct experience with participating in the process for national accreditation requirements (i.e., URAC, NCQA). Ability to maintain a high level of accuracy and attention to detail to perform each essential duty satisfactorily. Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals. Ability to write routine reports and correspondence. Ability to communicate effectively with other employees, Brokers, clients, vendors, and customers. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of basic mathematics and fundamental accounting principles. Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations.

To perform this job successfully, an individual must have basic knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software.

Licenses or Certification: Current, active, and unrestricted compact Registered Nurse license. Must maintain CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation