Role Description At International SOS, we are in the business of protecting and saving lives. For 40 years, we have delivered customised security risk management, health, and wellbeing solutions to organisations worldwide. With a presence in 90 countries and a team of nearly 13,000 experts, we provide 24/7 support to help organisations fulfil their Duty of Care responsibilities. The TOP Case Management Program Manager is an integral member of the TRICARE global Medical Team. The individual is responsible for managing the TOP Case Management Program to identify and support the management of the health care of individuals with high-cost conditions or with specific diseases or conditions for which evidence-based clinical management guidelines exist. The core and critical responsibilities of the role include: - Work collaboratively with superiors, peers, and other individuals in the completion of duties. - Ensure a high level of professionalism at all times when dealing with beneficiaries, colleagues, and TRICARE. - Ability to work within a remote team to actively drive a high level of service delivery. - Apply medical knowledge to high cost, unusual or complex requests for medical care. - Demonstrate written and oral communication skills to convey complex medical information. - Maintain an overview of any challenging or complaint cases and provide direction as required. Management of the TOP CMP - Establish, develop, standardize, and maintain quality of the TOP CMP. - Review all referred cases and provide determination regarding appropriateness of inclusion in the TOP CMP. - Allocate new cases to designated case managers for engagement and case management. - Monitor the case managers’ case assignment and workload distribution. - Hold regular meetings with the CMNs to facilitate case discussion and provide support. - Ensure TOP CMP cases are appropriately managed and provide case direction as required. - Promote and reinforce the need for evidence-based medical decision making. - Notify the MTF that the beneficiary has a qualifying diagnosis for case management. - Review and document case/cost savings due to the TOP CMP. - Work collaboratively with other business functions regarding identified billing and claims issues. Education - Provide TOP CMP induction and ongoing role specific education, support, coaching, and direction to the CMNs. - Provide TOP CMP education to other key stakeholders on an ad hoc basis. Client Interaction - Act as a subject matter expert regarding the TOP CMP. - Maintain a high level of client and procedural knowledge. - Participate in monthly TOP CMP case presentations to the TRICARE Area Office Medical Director/s and Nurses. - Present and participate in semi-annual surveillance audits. - Participate in any other client related duties as required. Reporting - Track and trend TRICARE beneficiaries who accept case management services. - Create and maintain dashboards within the CRM case management system. - Responsible for tracking, trending, and reporting of TOP CMP cases. - Act as the lead for the accurate and timely submission of the CDRL M010 – Monthly Case Management Report. - Support the completion and review of the annual CDRL – P050 Case Management Program Plan. - Assist with the preparation and/or presentation of other ad hoc reporting regarding the TOP CMP. - Act as the subject matter expert for the creation, review, and revision of Standard Operating Procedures (SOPs). Quality - Focus on quality-of-service delivery to ensure the highest possible levels are achieved. - Report to the TOP DoN the program progress, quality concerns, and submit feedback as needed. - Conduct internal and semi-annual surveillance audits of the TOP CMP. - Manage complaints in a professional manner, resolving them wherever possible. Other Duties - Work within a team and promote all International SOS & TRICARE policies and procedures. - Any other duties allocated by the TOP Director of Nursing and/or the TOP Head of Clinical Operations and Policy. - Work flexible hours as appropriate to the needs of the post. - Recognize limitations and areas of self-development through reflection. - Keep operational technical/functional skills and knowledge up to date. - Be responsible for own Continuing Professional Education. - Attend supervision, training, and departmental meetings as required. - Undertake accountability for workload. - Keep accurate records. Required Skills and Knowledge - Attention to detail. - Broad Medical Knowledge. - Effective communication skills. - Converses fluently in English. - Ability to provide clear and concise written updates in English. - Identifies and acts on potential problems. - Demonstrates appropriate listening skills. - Demonstrates effective problem-solving skills. - Able to work under pressure and prepare accurate reports. - Working knowledge of Microsoft Office applications. - Knowledge or familiarity with the TRICARE Overseas Program (preferred). - Positive motivation, encouragement, and influence skills. Required Competencies - Customer service oriented. - Empathetic and able to positively influence the customer journey experience. - Team player. - Has initiative, takes responsibility. - Ability to work independently. Required Qualifications - 3+ years clinical experience required. - US RN licensure required. - Nursing education qualification with maintained governance appropriate to country/body of qualification. - Case Management certification by recognized US body. - Managed care experience preferred. - TRICARE experience preferred. Required Languages - Excellent spoken and written English. - Additional language skills (particularly Spanish) are desirable, but not essential. Travel / Rotation Requirements - Flexible hours as appropriate to the needs of the post. - Ability to travel locally and internationally if required to support client and business functions preferred.