Role Overview
This position focuses on enhancing patient health through comprehensive case management. You'll work directly with individuals facing complex medical conditions, guiding them through care transitions and supporting long-term wellness. Reporting to the Associate Director, Clinical, you will play a key role in shaping effective care strategies and contributing to quality improvement initiatives.
Key Responsibilities
- Coordinate patient care across inpatient, outpatient, emergency, post-acute, and home health environments
- Initiate contact with members to assess needs and create individualized care plans
- Collaborate with hospital case managers to support timely and safe discharge processes
- Deliver health education via phone or secure messaging on diagnoses, treatments, and medication use
- Follow CCM NCQA standards in daily operations and clinical documentation
- Adhere to federal, state, and organizational regulatory requirements
- Support clinical projects and process enhancements as needed
Qualifications
Required
- Active, unrestricted U.S. Registered Nurse license in any state, or a valid multistate compact license
- Willingness to obtain additional state licenses based on operational needs
- Minimum of two years of clinical experience, including roles in payer organizations, hospitals, outpatient clinics, or community-based care management
- At least one year of direct experience in care coordination or patient navigation
Preferred
- Certified Care Manager (CCM) credential
- Familiarity with NCQA standards and accreditation processes
- Bilingual proficiency in Spanish or Haitian Creole (spoken, written, and read)
- Bachelor of Science in Nursing (BSN)
- Experience applying Milliman Guidelines in clinical decision-making
