Director, Case Management

Richmond, Virginia 23219


  • Full time

Job Description

The Director of Case Management is responsible for Program Management for the Case Management Program, primarily for the Medallion Medicaid program, with some interface with the MLTSS, MAPD, and DSNP programs. This includes the overall Case Management Program design, which involves the functions of the Case Management staff as well as monitoring staff performance in accordance with the DMAS contract and applicable Virginia Premier policies and procedures. Additional responsibilities include coordinating, conducting and documenting simple to complex Health Services projects and operational procedures and identification of process improvements/enhancements for care management.  Also is responsible for assisting in creating a strategic vision, process tools, and procedures to assure ongoing viability of operational performance of the Medical Management department and the organization
  • Provides clinical and operational oversight of each Health Services initiative which includes Case Management and the analysis of clinical data to drive performance improvement.
  • Reviews and revises Case Management Program Description annually or as indicated by contract or accreditation requirements.
  • Conducts annual evaluation of Case Management programs per contract or regulatory requirements.
  • Identifies, assesses, develops, and implements cross-functional, cross-departmental work processes that impact various departments or the company to improve clinical outcomes.
  • Identifies opportunities to improve clinical care, customer service and internal business processes.
  • Represents Medical Management for Medicaid Special Programs, including Foster Care and Medallion Care System Partnership (MCSP).
  • Ensures assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of Embedded Care Management programs in a variety of settings.
  • Collects, reports, trends, and analyzes Care Management program elements for departmental productivity and performance outcome reporting.
  • Validates Care Management quality audit results for accuracy and individual developmental needs.
  • Develops, implements, and monitors policies and procedures for contract and accreditation compliance.


  • Minimum education degree of Bachelors of Science in a health care field
  • License – Current Registered Nurse licensed to practice nursing in Virginia;
  • Certified Case Manager (CCM) preferred
  • Master’s degree preferred


  • Highly motivated individual with the ability to work independently as well as part of a team
  • Excellent verbal and written communication skills
  • Knowledge of NCQA and HEDIS
  • Knowledge of Medicaid and Medicare programs
  • Demonstrated knowledge of Care Management principles
  • Strong analytical problem-solving, time management, and organizational skills
  • Proficient Microsoft Office product computer skills
  • Proficient in Six Sigma or other performance improvement methodology
  • Ability to travel frequently to various VPHP locations throughout Virginia
  • Knowledge in program start-up and/or enhancements                                                                                       


  • Minimum of 5 years of case management experience preferably in a managed care setting
  • Minimum of 5 years of management experience
  • Knowledge of utilization management, preferably service authorizations related to waiver services
  • Minimum of 2 years of experience in Medicaid and Medicare managed care


  • Physical health sufficient to meet the ergonomic standards and demands of the position.
  • Regular local & state travel will be required


About Virginia Premier

Company Info

Shelby Brown

Richmond, VA, United States

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Director, Case Management


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