The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes. Requires an RN with unrestricted active license
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

The Care Manager—Registered Nurse is a key member of our Special Needs Plan (SNP) care team, responsible for coordinating care for members who often face multiple chronic medical and behavioral health conditions, as well as various social determinants of health (SDoH) needs. This role involves conducting comprehensive assessments to evaluate members’ needs and addressing SDoH challenges by connecting them with appropriate resources and support services. The Social Worker provides education and guidance to members and their families on managing chronic conditions and navigating the healthcare system. Additionally, the Care Manager develops and implements individualized care plans, monitors member progress, advocates for necessary services, and collaborates with the interdisciplinary care team to ensure optimal health outcomes. Accurate and timely documentation of assessments and interventions is essential, as is participation in team meetings to discuss member status and care strategies.
Duties
Key Responsibilities:

50-75% of the day is dedicated to telephonic engagement with members and the coordination of their care.
Compiles all available clinical information and partners with the member to develop an individualized care plan that encompasses goals and interventions to meet the member’s identified needs.
Provides evidence-based disease management education and support to help the member achieve health goals.
Ensure the appropriate members of the interdisciplinary care team are involved in the member’s care.
Provides care coordination to support a seamless health care experience for the member.
Meticulous documentation of care management activity in the member’s electronic health record.
Collaborate with other participants of the Interdisciplinary Care Team to address barriers to care and develop strategies for maintaining the member’s stable health condition.
Identifies and connects members with health plan benefits and community resources.
Meets regulatory requirements within specified timelines.
The Care Manager RN supports other members of the Care Team through clinical decision making and guidance as needed.

Additional responsibilities as assigned by leadership to support team objectives, enhance operational efficiency, and ensure the delivery of high-quality care to members. This may include participating in special projects, contributing to process improvement initiatives, or assisting with mentoring new team members.

Essential Competencies and Functions:
Ability to meet performance and productivity metrics, including call volume, successful member engagement, and state/federal regulatory requirements of this role.
Conduct oneself with integrity, professionalism, and self-direction.
Experience or a willingness to thoroughly learn the role of care management within Medicare and Medicaid managed care.
Familiarity with community resources and services.
Ability to navigate and utilize various healthcare technology tools to enhance member care, streamline workflows, and maintain accurate records.
Maintain strong collaborative and professional relationships with members and colleagues.
Communicate effectively, both verbally and in writing.
Excellent customer service and engagement skills.

Experience
Must have active and unrestricted Registered Nurse (RN) licensure in the state of Alabama OR compact licensure in state of residence
Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams, with the ability to effectively utilize these tools within the context of the CM RN role.
Access to a private, dedicated space to conduct work effectively to meet the requirements of the position.
Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually.
Minimum 3+ years of nursing experience
Minimum 2+ years of case management, discharge planning and/or home healthcare coordination experience

Preferred Qualifications
Experience providing care management for Medicare and/or Medicaid members.
Experience working with individuals with SDoH needs, chronic medical conditions, and/or behavioral health.
Experience conducting health-related assessments and facilitating the care planning process.
Bilingual skills, especially English-Spanish

Education
Associate’s of Science in Nursing (ASN) degree and relevant experience in a health care-related field (REQUIRED)
Bachelor’s of Science in Nursing (BSN) (PREFERRED)

License
Must have active and unrestricted Registered Nurse (RN) licensure in the state of X OR compact licensure in state of residence

Education
RN with current unrestricted state licensure.
Case Management Certification CCM preferred

REQUIRED:
Must have experience working a remote position previously.
Must have case management experience.

Notes:
Monday - Friday 8 to 5 EST
Fully remote (never coming onsite)
safety sensitive