Care Manager, RN

Responsibilities

• Conduct comprehensive health assessments, including medical, behavioral, and social determinants of health (SDOH)
• Develop, implement, and evaluate individualized care plans based on member needs, goals, and risk level
• Coordinate care across multiple settings, including inpatient, outpatient, and community-based services
• Facilitate transitions of care, including hospital discharge planning and post-discharge follow-up
• Utilize clinical expertise to identify gaps in care, potential risks, and opportunities for early intervention
• Monitor member progress and adjust care plans accordingly
• Provide education to members and caregivers regarding disease management, medications, and treatment plans
• Apply evidence-based guidelines and best practices in care management
• Support appropriate utilization of healthcare services to ensure cost-effective care delivery
• Collaborate with utilization management teams to reduce avoidable hospitalizations and emergency department visits. Identify high-risk members and implement strategies to improve outcomes and reduce healthcare costs
• Partner with physicians, specialists, behavioral health providers, and community agencies to coordinate care
• Serve as a liaison between members, providers, and health plan resources
• Participate in interdisciplinary team meetings and case conferences
• Maintain effective communication to ensure continuity of care
• Ensure timely and accurate documentation in accordance with regulatory, CMS, and organizational requirements
• Support quality improvement initiatives, including HEDIS, STAR ratings, and other performance measures
• Maintain compliance with accreditation standards and internal policies
• Conduct outreach to engage members in care management programs
• Promote self-management and adherence to treatment plans. Address barriers to care, including social, economic, and cultural factors

• Bachelor of Science in Nursing (BSN) preferred;
  Associate degree in Nursing required
• At least 2 years of clinical nursing experience (case management, acute care, or managed care preferred)
• Certifications & Licensure Active, unrestricted Registered Nurse (RN) license
• ACM (Accredited Case Manager) certification required or must be obtained within a specified timeframe
• CCM (Certified Case Manager) may be considered in lieu of or in addition to ACM (depending on organizational requirements)
• Strong knowledge of care management principles, utilization management, and population health
• Understanding of regulatory standards (CMS, NCQA, etc.). Ability to assess and manage complex clinical and psychosocial situations
• Excellent communication, collaboration, and critical-thinking skills
• Proficiency in electronic health records (EHR) and care management documentation systems
• Ability to manage multiple priorities in a fast-paced environment
• Experience in care coordination, discharge planning, or population health strongly preferred

• clinical nursing
• case management
• acute care
• managed care
• care coordination
• discharge planning
• population health
• evidence-based guidelines
• health assessments
• risk assessment

• communication
• collaboration
• critical thinking
• organizational skills
• interpersonal skills
• problem-solving
• education
• adaptability
• time management
• teamwork

• Registered Nurse (RN) license
• Accredited Case Manager (ACM)
• Certified Case Manager (CCM)