SummaryThe Manager of Large Case Management is responsible for the overall leadership, strategy, and performance of the Large Case Management (LCM) function. This role oversees clinical operations for high-cost and complex medical cases, ensuring quality member outcomes, regulatory compliance, and financial stewardship. The Manager leads Supervisors and case management staff, drives operational excellence, and partners cross-functionally to optimize care delivery and cost containment strategies. This role is accountable for program development, vendor strategy, reporting, and continuous improvement initiatives that enhance clinical and financial outcomes. The Manager reports to the Director of Case Management and may require intermittent travel.
Responsibilities- Provide strategic and operational leadership for the Large Case Management program, ensuring alignment with organizational goals and clinical best practices.
- Oversee daily operations through direct leadership of Supervisors, ensuring productivity, quality, timeliness, and documentation standards are met.
- Establish and monitor key performance indicators (KPIs),identifying trends and implementing action plans to improve outcomes and efficiency.
- Lead the development and execution of case management strategies for high-cost and complex cases to optimize clinical outcomes and financial impact.
- Support Case Management vendor strategy, performance monitoring, and evaluation ofreferral appropriateness and outcomes.
- Ensure compliance with all accreditation, regulatory, and contractual requirements (e.g., state, federal, URAC, NCQA, HIPAA).
- Partner with Finance and leadership to ensure accuracy, integrity, and insights within stop loss reporting and high-cost claim analysis.
- Lead internal and external audits, quality assurance initiatives, and regulatory readiness efforts.
- Collaborate cross-functionally with Utilization Management, Claims, Network, and Client Services to drive coordinated care and program effectiveness.
- Identify and implement process improvements to enhance quality, efficiency, and scalability of the case management program.
- Develop, implement, and maintain policies, procedures, and clinical guidelines for case management operations.
- Provide leadership, mentorship, and development for Supervisors and team members, including performance management and career progression planning.
- Oversee hiring, onboarding, training, and workforce planning to ensure appropriate staffing and capability development.
- Communicate program performance, outcomes, and strategic insights to senior leadership.
- Lead and support change management initiatives within scope of responsibility.
- Performs other duties as assigned
Qualifications- Registered Nurse with a minimum of 3-5 years of clinical nursing experience.
- Minimum of 3 years in a healthcare leadership role (e.g.team lead or higher)
- Bachelor's Degree from an accredited college or university required
- Demonstrated ability to manage and lead a team of direct reports
- Excellent written and oral communication skills
- Strong analytical skills with attention to detail
- Ability to identify areas of improvement and develop action plan to address findings
- Positive, proactive team-oriented approach/attitude
- Strong knowledge of Microsoft Office products
- Holds a current, active, and unrestricted RN license that allows him/her to practice in a state or territory of the United States.
- Relevant certifications such as Certified Case Manager (CCM) may be preferred.
