Lead Case Manager

PruittHealth Case Management Lead

To develop, lead, and support the Case Management (CM) program in support of PruittHealth Premier while providing oversight of clinical care management activities for the Dual Eligible Special Needs Plan (D-SNP) population. The position is responsible for establishing and implementing protocols, policies, procedures, training, and supervision of Nurse Practitioners while ensuring effective interdisciplinary care coordination, case management integration, quality improvement initiatives, and compliance with CMS and PruittHealth Premier standards. The Lead CM serves as an active practicing provider and clinical resource supporting community-based members.

Key Responsibilities

Clinical Leadership

• Develop and implement CM program protocols, policies, procedures, and workflows.
• Provide day-to-day supervision, mentoring, coaching, and training of assigned plan case management staff
• Conduct routine case management reviews
• Participate in case management staff recruitment, interviewing, onboarding, orientation, and performance evaluations.
• Manage staffing schedules, on-call schedules, PTO approvals, and workforce coverage planning.
• Collaborate with leadership, PCPs, facilities, and interdisciplinary teams to improve quality outcomes and support CMS initiatives.

Clinical Practice

• Complete Health Risk Assessments (HRAs), annual wellness evaluations, and comprehensive care planning activities.
• Reconcile medications and coordinate treatment plans with physicians and pharmacists.
• Work with team to ensure accurate ICD-10 documentation and regulatory compliance.

Case Management & D-SNP Oversight

• Provide oversight of clinical care management activities across the continuum of care.
• Support development and monitoring of individualized care plans (ICP).
• Coordinate transitions of care and ensure ICP communication within required timeframes.
• Monitor member progress and revise plans of care as clinical needs change.
• Collaborate with Care Navigators, Member Advocates, Social Workers, Pharmacists, PCPs, and Specialists.
• Facilitate interdisciplinary care team meetings for high-risk members.
• Coordinate discharge planning, transition management, specialist referrals, transportation coordination, and supplemental benefit advocacy.
• Assist with care coordination for members residing in skilled nursing facilities
• Ensure members understand benefits, available resources, medications, treatment plans, and care options.
• Support disease management, triage functions, and population health initiatives as necessary.

Quality & Regulatory

• Lead and participate in Quality Assurance Performance Improvement (QAPI) activities.
• Identify quality improvement opportunities and corrective action plans.
• Ensure compliance with CMS requirements, HIPAA regulations, and PruittHealth Premier standards.
• Monitor quality metrics including model of care metrics, HEDIS/STARS metrics and care management outcomes. Ensure Plan Case Managers are addressing and following up on metrics that are below goal.
• Participate in audits, reporting activities, and documentation reviews as required

Education & Member Engagement

• Provide education to members, caregivers, providers, and clinical staff.
• Support community outreach and educational marketing initiatives.
• Promote evidence-based practice, professional development, and best-practice standards.
• Serve as a clinical resource and subject matter expert for care management team.
• Train new D-SNP team members

Other Duties

• Travel to member locations as required.
• Perform other duties as assigned by leadership.

Knowledge, Skills, Abilities

• Clinical assessment and diagnostic expertise.
• Managed care, and D-SNP knowledge.
• Case management and care coordination expertise.
• Understands the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decisions makers.
• Knowledge of CMS regulations and Model of Care requirements.
• EMR, care management platform, Microsoft Office, and reporting proficiency.
• Strong leadership, mentoring, coaching, and team development skills.
• Excellent communication and interpersonal skills.
• Ability to prioritize multiple assignments and manage complex clinical situations.
• Strong analytical, organizational, and problem-solving ability.
• Ability to work independently and collaboratively across disciplines.

Minimum Education Required

• Bachelors (or higher) degree preferred.
• Additional leadership or care management training preferred

Minimum Experience Required

• Minimum five (5) years clinical experience as a nurse in the community or managed care setting and at least two years case management, home care or hospice experience strongly preferred.
• Experience leading healthcare professionals and interdisciplinary teams.
• Experience working with Dual Eligible Special Needs Plans (D-SNP) and/or Institutional Special Needs Plans (I-SNP) preferred.

Minimum Licensure/Certification Required by Law

• Current and unrestricted RN licensure in state of practice.
• Certified Case Manager (CCM) preferred
• Current CPR Certification.

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