Job Description

Your Role

The Care Management team independently manages complex and high-risk care management cases by applying advanced clinical judgment to assess medical necessity, develop cost-effective care plans, and support quality outcomes aligned with benefit and contract requirements. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care, support discharge planning, evaluate barriers to care, and ensure members receive appropriate referrals and continuity of treatment. This position also requires ongoing reassessment of care plans, awareness of healthcare trends and clinical guidelines, and the ability to participate in a rotating evening and weekend on-call schedule.

Responsibilities

Your Work

In this role, you will:

• Work with minimal supervision to manage complex care management cases
• Apply advanced clinical judgment to assess medical necessity and appropriateness of care
• Design and implement treatment and care plans that promote quality, cost-effective outcomes aligned with benefit and contract requirements
• Coordinate discharge planning activities for complex and high-risk cases
• Determine appropriateness of referrals to care management and specialty programs
• Collaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuity
• Evaluate member health behaviors, cultural influences, and belief systems to identify barriers to care
• Contribute clinical input to medical directors and support informed decision making
• Continuously improve outcomes by anticipating barriers and adjusting plans of care based on reassessment, clinical changes, and guideline updates
• Maintain current knowledge of healthcare service trends, regulations, and clinical practice guidelines
• Ability to work evenings and weekends as part of rotating on-call schedule
• Perform other duties as assigned

Qualifications

Your Knowledge and Experience

• Associate Degree in Nursing required or master's degree in relevant field for non-RN licensure.
• Bachelor of Science in Nursing is preferred
• 5 years of experience in nursing, healthcare, or a related clinical field
• 3 years of managed care experience preferred
• Certified Case Manager (CCM) is preferred
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans
• Advanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditions
• Demonstrated competence in care management functions and standards of practice
• Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs
• Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.