Rn Care Manager - Complex Care & Utilizer Management

Job Responsibilities Core Responsibilities

• Chronic Disease Management
• Deliver ongoing care, support, and health education to participants with chronic illnesses including COPD, Diabetes, Heart Failure, cardiovascular disease, and degenerative neurological or musculoskeletal disorders.
• Facilitate and enable engagement with the CL provider and IDT
• Design and lead the implementation of care pathways and clinical protocols to streamline the management of the most common chronic illnesses.
• Develop and implement individualized chronic disease action plans to prevent avoidable ED visits, hospital readmissions, and disease exacerbations in collaboration with TOC and IDT.
• Conduct clinical reviews using evidence-based criteria to ensure appropriateness of care for chronic disease–related needs.
• High Utilizer Oversight (Outpatient, Inpatient & ED)
• Lead clinical management of participants identified as high utilizers of outpatient care or at elevated risk for hospital or ED use.
• Perform risk stratification emphasizing chronic disease burden and complex behavioral health conditions such as COPD, CHF, Diabetes, and psychiatric comorbidities.
• Monitor utilization patterns and proactively engage participants to reduce unnecessary, repetitive, or avoidable service use
• Collaborate with behavioral health staff to address psychosocial, psychiatric, or adherence related barriers that contribute to high utilization.
• Oversee the referral process for high-risk and complex participants to ensure clinical appropriateness and timeliness.
• Collect and evaluate clinical documentation supporting medical necessity for specialty services, chronic disease care, and behavioral health interventions.
• Prioritize urgent referrals and coordinate follow-through for participants at highest medical risk.
• Support participants in navigating the healthcare system and reinforce chronic-condition self-management practices.
• Respond to participant concerns related to care access, delays, or coordination and resolve barriers in real time.
• Care Coordination & Communication
• Work closely with Center Light physicians, behavioral health teams, and external providers to ensure cohesive, risk reducing care coordination
• Maintain current knowledge of Center Light's provider network, including behavioral health and chronic disease specialties such as COPD, CHF, and Diabetes care.
• Communicate care trends, system changes, and clinical insights to the CMO and IDT.
• Serve as the Clinical Programs’ subject matter expert, coordinating with TOC, Social Work Care Managers, Clinical Review Specialists, and the IDT for high-risk or complex cases.
• Partner with TOC on safe discharge planning and transitions to reduce readmissions.
• Quality & Performance Improvement
• Conduct prospective, concurrent, and retrospective clinical reviews related to chronic disease and complex care management.
• Apply evidence-based guidelines to determine medical necessity for participants with frequent ED visits, behavioral health complexity, or chronic disease complications.
• Participate in quality improvement initiatives, including inter‑rater reliability testing.
• Support HR‑HI provider panel updates and contribute clinical insights to enhance risk reduction and chronic disease control.
• Perform other duties as assigned.

Schedule: 8:30AM – 5:30PM,
remote option only applicable in NY.

Weekly

Hours:

40

• BSN required
• Current Registered Nurse (RN) license in New York State
• Certification in Case Management (CCM) or equivalent, preferred

• 3+ years of clinical experience in chronic disease management, care coordination, or case management
• Experience working with high‑risk, medically complex, or high‑utilizing populations
• Strong assessment, communication, and interdisciplinary collaboration skills
• Experience in PACE, MLTC, Managed Care, or high‑risk care management preferred
• Prior experience with behavioral health integration or complex psychosocial case management preferred

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment,…