Manager, Case Management of Low and Emerging Risk

Manager Of Case Management For Rising And Emerging Risk

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Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Manager of Case Management for Rising and Emerging Risk leads a specialized team focused on early identification, proactive engagement, and targeted interventions for members showing early signs of increasing health risk. This leader is responsible for ensuring members receive the right level of support at the right time to prevent avoidable escalation into moderate or high-risk categories. The role includes strategic oversight, operational leadership, and staff development to deliver high-quality, coordinated care management services that stabilize member health, reduce future utilization, and advance Pacific Source's population health goals.

Essential Responsibilities :

• Responsible for oversight, management, development, implementation, and communication of department programs.
• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.
• Oversee the use of risk-stratification tools, predictive analytics, and member segmentation to identify rising-risk members early and prevent escalation into moderate or high-risk tiers.
• Partner with Analytics to refine forecasting models and ensure actionable data drives daily workflows and intervention strategies.
• Align closely with Transitions of Care teams to reduce re-admissions and maintain continuity of care.
• Ensure case management activities, documentation, and care plans meet regulatory and accreditation standards (e.g., CMS, OHA, NCQA).
• Monitor and improve member satisfaction, engagement, and activation in the care management program.
• Promote person-centered care by ensuring individualized care plans reflect member goals, preferences, and cultural considerations.
• Track outcomes for program improvement and support continuous optimization of member interventions.
• Develop short- and long-term strategic plans for the rising / emerging risk program, ensuring alignment with enterprise goals including Member Bridge and cost-of-care initiatives.
• Lead readiness efforts for major organizational initiatives (e.g., Epic, new analytic tools, vendor partnerships).
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
• Actively participate as a key team member in Manager / Supervisor meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Lead and manage case management programs for rising and emerging risk populations, ensuring compliance with regulatory standards and organizational objectives.
• Collaborate with Health Services leadership and cross-functional teams to design, implement, and optimize care management processes, including physical and behavioral health integration.
• Develop and maintain workflows and data systems to track caseloads, program effectiveness, and patient outcomes, ensuring timely reporting and actionable insights.
• Provide leadership in hiring, training, coaching, and performance management of case management staff, fostering a culture of collaboration, accountability, and professional growth.
• Ensure timely communication of high-cost or complex cases to finance, underwriting, and leadership teams for risk mitigation and resource planning.
• Serve as a liaison with internal departments, provider networks, and community partners to coordinate care management programs that enhance member outcomes.
• Oversee and participate in clinical interdisciplinary rounds with our medical directors, utilization management, disease management, appeals and grievance and behavioral health to ensure members' needs are met.
• Monitor adherence to privacy standards and regulatory requirements, maintaining the integrity of personal health information.
• Establish and track goals for care management programs related to caseloads, timeliness, quality, and member outcomes, and report progress to senior leadership.
• Establish and track goals pertaining to enterprise metrics related to reduction in length of stay, reduction in readmission and reduction in hospital admissions.
• Stay current with best practices in case management and care coordination through continuing education and apply innovative models of care.

Supporting Responsibilities :

Success Profile

Work Experience : Minimum 5 years in case management or care coordination required. 3 years direct health plan experience in case management, disease management, care coordination, or equivalent preferred. Prior supervisory or management experience required.

Education, Certificates, Licenses : Registered Nurse or Licensed Clinical Social Worker or other licensed healthcare or behavioral health care clinician, Oregon licensure required. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire.

Knowledge : Thorough knowledge and understanding of medical and behavioral health procedures, diagnoses, and treatment modalities, procedure codes, including ICD-9 & 10, DSM-IV & V, CPT codes, health insurance and State of Oregon mandated benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Strong knowledge of health insurance; including managed care products as well as state mandated benefits. Ability to develop, review and evaluate utilization and care management reports. Experience in adult education preferred. Proficient in the use and implementation of the following tools and concepts across all teams within scope and accountability : Training, Coaching, Strategy Deployment, Daily Operations, Visual Management, Operational Improvement & Team Building / Development.

Competencies : Building Trust, Building a Successful Team, Aligning Performance for Success, Building Partnerships, Customer Focus, Continuous Improvement, Decision Making, Facilitating Change, Leveraging Diversity, Driving for Results.

Environment : Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 20% of the time.

Skills : Accountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking

Our Values : We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business :

Physical Requirements : Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.