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Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Supervisor, Complex Case Management - Atlanta

Location: Atlanta, GA Job Number: 914553 Date posted: 10/29/2020

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The Complex Case Manager Supervisor is responsible for supporting the Manager of Complex Case Management (CCM) and Elder Care. Duties include daily supervision and monitoring of case management activities. The activities to be supervised are assessment of need, planning of care/development of treatment plan, implementation of plan of care, monitoring and coordinating care based on treatment plan, evaluation of case management, communication with member and providers, education, and management of care along the continuum. Interacts with the following: Inpatient Case/Care Management staff, Transition staff, QRM staff, Population Care staff, Medical Office staff, Social Workers, Vendors and other KPGA staff. Promotes a high level of quality care and member and/or caregiver satisfaction.

Essential Responsibilities:
  • Oversees the activities of the Complex Case Managers including assessment, planning, implementing, coordination, monitoring and evaluating case management.
  • Acts as a resource for the case managers as well as physicians, health plan administrators and contracted vendors. He/she will assist the staff with problem solving and difficult cases.
  • Performs monthly or quarterly audit in accordance with established protocols to ensure documentation of the case management processes are performed consistently and in accordance to NCQA standards. Performs an analysis of audit result with staff and reports findings to Manager, upon request.
  • Determine daily work assignments to ensure that case management services are rendered in the most effective and efficient manner.
  • Develops individual performance objectives for staff and ensures that competence of staff meets departmental standards.
  •  Coordinates and participates in case conferences as needed with all providers involved in the care and updates the plan of care as necessary.
  • Builds effective working relationships with physicians and their staff, hospitals, vendors, and other departments within the health plan, and functions as a liaison with other departments and appropriate personnel to facilitate the case management process and to provide continuity of care.
  • Coordinates and assists with ongoing physician and health care team education on the role of case management.
  • Assists Management team with the investigation and resolution of any concerns and acts as back-up for the Manager to ensure compliance with NCQA standards.
  • Investigates, identifies and reports problems and inefficiencies in existing systems and/or work-flows and recommends changes when appropriate to Manager or other departments.
  • Remains knowledgeable of contract benefits and current, relevant state and Federal regulations (includes CMS), criteria, documentation requirements and laws that affect managed care and case/utilization management. Educates staff and physicians on the changes and the implications of the changes.
  • Performs quality of care and service reviews as needed. Using quality indicators, ensures the Case Management (CM) team refers cases identified as risk management or quality issues to Quality and Risk Management.
  • Assists Manager in the development and revision of guidelines, pathways and protocols. Participates in the coordination, planning, development, implementation, and maintenance of Quality policies and procedures at the service area level.
  • As needed, participates in Marketing RFI/RFP process, performance guarantees, information gathering, and group meetings as requested.
  • Maintains awareness of utilization trends in the market area, keeping appropriate management informed.
  • Basic Qualifications:
  • Minimum five (5) years of clinical nursing. Must possess clinical nursing experience in an area such as ICU, ER, medical surgical or skilled nursing care.
  • Minimum three (3) years of supervisory experience in UM/Case Management in an HMO/ managed care insurance industry.
  • Education
  • Bachelor's degree in nursing OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
  • License, Certification, Registration
  • Unrestricted current RN licensure in the state of Georgia required or able to obtain prior to date of hire.
  • CCM certification by CCMC required or certification obtained within 12 months of hire.

  • Additional Requirements:
  • Intermediate Excel and data analysis.
  • NCQA or URAC accreditation survey experience.
  • Managed Care experience preferred and/or strong UM background.
  • Knowledge of ICD9/ ICD10 and/or CPT4 coding beneficial.
  • Experience with managed health care delivery including Medicare.
  • Working knowledge of all relevant federal, state, local and regulatory requirements including Medicare/CMS.

  • Preferred Qualifications:
  • Complex Case Management experience and national board certification for a minimum five (5) years.
  • Minimum three (3) years of experience in utilization or case management, discharge planning and/or quality improvement in a managed care setting.
  • Bachelor's degree in nursing strongly preferred.
  • Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon - Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-GA-01|NUE|Non Union Employee Job Level: Team Leader/Supervisor Job Category: QA / UR / Case Management Department: Rgnl Mg Admn-Ccs Case Coord Travel: Yes, 5 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

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    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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