Manager, Clinical Care Management

Summary of Position

Provide clinical leadership and oversight to Care Managers and Community Health Workers serving members with complex medical, behavioral health, and social needs. Ensure delivery of evidence-based, member-centered, whole-person care that addresses physical health, behavioral health, and social determinants of health. Direct daily care management operations, including caseload distribution, workflow optimization, timely documentation, and management of high-risk, high-cost populations. Utilize quality, outcome, productivity, and service-level data to evaluate performance, address operational barriers, and improve program effectiveness and efficiency. Maintain regulatory and accreditation compliance while collaborating across clinical and operational teams to advance quality, member experience, and cost-of-care outcomes.

Principal Accountabilities

• Manage daily operations of the Care Management team including measurement of performance metrics and productivity standards; implement, deploy, and reinforce strategies to improve performance.
• Provide regular case consultation, clinical supervision, and mentoring to team members to ensure clinical rigor, productivity, and address performance-related issues.
• Monitor timeliness and appropriateness of documentation in clinical systems to ensure that documentation meets accreditation and regulatory standards.
• Ensure that team members are managing enrollees across the care continuum, inclusive of behavioral health, so that enrollees have access to needed care and services.
• Provide clinical oversight and direction to Care Managers and Community Health Workers supporting members with complex medical, behavioral health, and social needs.
• Ensure delivery of evidence-based, member-centered care management interventions.
• Support appropriate stratification and management of high-risk, high-cost populations.
• Monitor clinical decision-making for consistency with health plan policies, regulatory requirements, and professional standards.
• Ensure timely completion of assessments, care plans, outreach activities, and documentation.
• Utilize data to monitor team member and program performance, including quality, outcomes, productivity, and service levels, and deploy strategies to improve program efficiency and effectiveness.
• Identify operational barriers and implement process improvements.
• Collaborate with utilization management, behavioral health, pharmacy, quality, and provider teams.
• Train employees in process operations; act as a preceptor to newly hired staff.
• Monitor employees' performance regularly and coach employees as needed.
• Ensure compliance with NCQA, CMS, state, accreditation, and organizational standards.
• Participate in audits, quality reviews, and corrective action plans.
• Monitor adherence to care management programs, policies, and documentation requirements.
• Support quality improvement initiatives focused on clinical outcomes, member experience, and cost of care.
• Serve as a clinical resource; attend Care Management rounds.
• Perform other related tasks as directed or required.