Manager, Clinical Programs

Under the general direction of the Director, Clinical Services, the Manager, Clinical Programs will be responsible for the oversight of both delegated and non-delegated Case Management programs.
Programs include: Complex Case Management, Intensive Case Management Program, OB Case Management, End-Stage Renal Disease (ESRD) Case Management, CBAS and CCS. This position will oversee members’ needs by providing the necessary Alliance, medical and community resources to promote cost effective care with quality outcomes. The Manager, Clinical Programs will also be responsible for the development and execution of this unit, budget administration, hiring and managing staff as well as ongoing management and operations of this unit and its processes.

Principal responsibilities include:
• Oversee the programs in Case and Disease Management to include, but not limited to, Diabetes Management, Asthma Management and Complex Case Management.
• Oversee the Clinical and day-to-day care coordination needs of members in the Intensive Case Management Program, both through direct staff as well as through contracted Community Base-d Organizations.
• Assist Compliance in delegation oversight activities for those case management programs delegated to external vendors
• Oversee the OB Case Management program, to meet the goals as described in Performance Improvement Plans
• Oversee the End-Stage Renal Disease program to meet the goals of better health outcomes while decreasing avoidable hospital and ER utilization
• Oversee CBAS and CCS case management and coordination
• Identify, develop, and manage any additional programs and processes to identify and manage high risk members to improve member’s health outcomes and prevent hospitalizations.
• Assist in writing and implementing business requirements for any software systems that will be used in the assessment, care coordination and case management processes.
• Oversee the collection, analysis, and reporting of Case and Disease Management based on NCQA, state, and federal standards. Recommend process and performance improvement for the CM/DM programs. Ensure that all state and federal requirements are supported by the current program policies and IT platforms.
• Implement methods to recruit and retain expert staff including hiring, developing, mentoring, training, and retaining competent staff.
• Monitor intake and assessment, care coordination and case managers’ productivity.
• Engage internal and external stakeholders in care coordination/case management processes, promote interdisciplinary collaboration, foster teamwork, and champion service excellence in keeping with organizational goals.
• Appropriately manage people, relationships, and processes in order to achieve maximum results.
• Complete and conduct annual performance evaluations with staff.
• Develop and manage the departmental budget and track monthly variances. Oversee expense and revenue utilization.
• Provide quality care services measured by consistent achievement of professional standards and the satisfaction of customer expectations.
• Provide education and promote understanding of care coordination, case management, social services, and quality improvement issues.
• Participate on compliance, finance, contracting, regulatory, and other multidisciplinary committees that foster organizational improvement.
• Anticipate, identify, and analyze care issues and trends, make appropriate recommendations, develop and implement best practice pilot projects aimed at reducing medical costs and improving quality healthcare outcomes.
• Work closely with the Alliance management team to identify medical and social services issues that have an impact on plan benefits and their administration.
• Review quality concerns identified through the QI process and oversee the implementation and monitoring of relevant corrective action plans.
• Prepare for and participate in regulatory audits and develop and monitor corrective actions plans.
• Oversee department workload and ensure that timely and effective adjustments are made.
• Oversee the development of policies and procedures.
• Administer a program for the development, preparation and maintenance of appropriate and required records, data, processes, policies and procedures.
• Complete other duties and special projects as assigned.

• Bachelor’s Degree in nursing required.
• Current and unrestricted California RN license.
• Knowledge of managed health care as applied to government sponsored programs preferred.
• Knowledge of managed care systems in a Knox-Keene licensed HMO preferred.


• Minimum five years in management level experience for a qualified case management program in a health care and community-based setting required.


• Ability to build a strategic plan and operationalize it.
• Ability to build and manage an administrative budget.
• Ability to plan for, hire and supervise staff, and ensure that direct reports supervise staff in a manner that maximizes employee performance and business results.
• Possess very strong coaching/counseling skills including the ability to function as a mentor to management and employees.
• Ability to motivate and train staff.
• Ability to speak and be understood in English.
• Ability to communicate effectively, both verbally and in writing.
• Ability to handle confidential information with appropriate discretion.
• Basic understanding of regulatory and compliance issues involving case and disease management.
• Ability to work with and use clinical data effectively to improve efficiency and effectiveness of care.
• Ability to make thoughtful decisions and exercise sound judgment.
• Strong financial analytical skills.
• Strong problem solving skills.
• Ability to work effectively in a multidisciplinary approach to management.
• Flexibility and creativity a must.
• Familiarity with programmatic and clinical research strategies in a managed care setting preferred.
• Proficient experience in Microsoft Word, Microsoft Excel, Outlook, and Microsoft PowerPoint.

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