Job Description:The RN Case Manager provides telephonic and digital case management services to health plan members, focusing on supporting patients after emergency department visits or hospitalizations to ensure smooth transitions and prevent readmissions. Case management is a collaborative, patient-centered process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet health and human service needs. The role emphasizes advocacy, communication, care coordination, and resource management to promote high-quality, cost-effective outcomes. This position operates in a fully virtual environment, requiring proficiency with telephonic platforms, electronic documentation, and multi-system navigation.
ESSENTIAL RESPONSIBILITIES:Core Case Management Activities- Identify members appropriate for case management based on clinical indicators, referrals, utilization patterns, and health-related concerns.
- Conduct comprehensive assessments of members' physical, psychosocial, behavioral, and environmental needs and barriers.
- Develop individualized care plans aligned with member goals, provider recommendations, and established standards of practice.
- Implement and coordinate interventions to address barriers, enhance access, and support successful goal achievement in collaboration with physicians, caregivers, and other providers.
- Document assessments, interventions, care plans, progress notes, and member interactions within the case management system according to policy and regulatory criteria.
Ambulatory Case Management Responsibilities- Provide structured case management services for ambulatory and outpatient populations, including those with chronic or complex conditions.
- Conduct proactive outreach to members identified through data analytics, referrals, or quality measures to support early engagement and intervention.
- Coordinate care across primary care, specialty care, behavioral health, pharmacy, and community resources to ensure cohesive outpatient support.
- Facilitate timely follow-up after emergency department visits, urgent care visits, or hospital discharges to ensure continuity of care.
- Reinforce treatment plans, promote medication adherence, and support self-management for chronic disease populations (e.g., diabetes, COPD, CHF).
- Monitor member progress and adjust care plans based on evolving needs and medical provider feedback.
- Identify and address social determinants of health, connecting members with community-based support and resources.
- Track ambulatory utilization and collaborating with internal teams to reduce avoidable ER use and close care gaps.
Additional Responsibilities- Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory, and accreditation standards.
- Ensure compliance with department procedures, turnaround times, and documentation standards.
- Support interdisciplinary care processes to promote optimal resource utilization and quality outcomes.
- Maintain and update community resource databases and internal referral pathways.
- Utilize reporting tools and internal systems to identify trends, monitor resource utilization, and support quality improvement initiatives.
- Refer members to appropriate departments such as Health Education, Quality Management, Contracting, Provider Services, and others as needed.
- Issue member communications in accordance with department policies.
- Support the Medical Management Team, including Authorization Review, Clinical Initiatives, and Provider Education functions.
- Participate in internal and external meetings, training, and educational programs to maintain and enhance case management competencies.
- Perform other duties as assigned.
Required Experience- Minimum 5 years of experience required, including:
- At least 3 years of clinical nursing experience in areas such as medical-surgical, critical care, home health, or skilled nursing.
- At least 2 years of experience in case management, utilization management, discharge planning, or quality improvement in a managed care setting.
- Experience with managed care delivery, including IPA networks and Medicare.
- Strong organizational skills with ability to meet both expected and unexpected time frames.
- Excellent verbal and written communication skills.
- Proficiency in Microsoft Outlook, Teams, and electronic charting systems.
- Ability to navigate multiple platforms and document while engaging with members.
- Ability to coordinate effectively with members, providers, office staff, health plans, internal departments, community resources, and peers.
- Ability to work independently with self-initiative and discipline.
- Knowledge of ICD-10 and CPT coding.
- Working knowledge of personal computers.
Hybrid/Remote Work Requirements- Dedicated office space that is free from distractions, with a door that closes and appropriate office furniture.
- Staff cannot be the primary caregiver to any person during business hours.
- High-speed internet connection.
- Ability to be on camera during department meetings or calls with peers or leaders.
Required Education- Associate degree in Nursing (A.S.) required.
- Unrestricted California Registered Nurse licensure: certification in case management preferred
Additional InformationSalary: $100,000 - $123,000 Annual
