The Complex Care RN (CCM RN) serves as the clinical center of the Care Anywhere pod - owning the member journey, coordinating care across disciplines, and ensuring the highest-acuity Medicare Advantage members receive timely, proactive, and coordinated care in a fully virtual delivery model. Embedded within a team-based pod alongside APCs, Health Coaches, Care Coordinators, Medical Assistants, and Social Workers, the CCM RN manages transitions of care, drives member engagement cadence, escalates clinical concerns, and serves as the central coordination point for all caregivers involved in a member's care. This role is critical to the approved virtual health model because the CCM RN directly enables APCs to work at the top of their license - handling the coordination, monitoring, and transition work that would otherwise consume APC time - and ensures the organization's most vulnerable members never fall through the cracks.

Job Responsibilities:

Own the Member Journey and Care Coordination for High-Acuity Members.
Serve as the primary care coordinator for an assigned panel of medically complex, high-risk Medicare Advantage members - maintaining consistent engagement cadence, proactively monitoring clinical status, and ensuring all care activities across the pod are connected and moving forward. Build trusted relationships with members and their caregivers through regular telehealth outreach - identifying changes in condition, barriers to care, and social needs that require intervention.

Manage Transitions of Care and Hospital Discharge Coordination.
Own transitions of care for members discharging from hospitals, SNFs, and other inpatient settings - completing timely post-discharge outreach, medication reconciliation, and follow-up coordination to reduce avoidable readmissions and support safe, effective transitions back to the community. Ensure all members' care plans are updated following transitions and that all pod team members have the clinical context needed to support the member.

Complete Medication Reconciliations and Clinical Monitoring.
Conduct medication reconciliations for assigned members - reviewing medication lists for accuracy, appropriateness, and adherence, identifying potential interactions or concerns, and escalating clinical findings to the APC as appropriate. Monitor for symptom changes, lab values, and care gap alerts - facilitating outreach and coordinating responses across the pod when abnormal findings require action.

Escalate Clinical Concerns and Support APC Clinical Decision-Making.
Serve as the first clinical escalation point within the pod - triaging member clinical concerns, assessing urgency, and routing to the members PCP, CAW APC or RMO for provider-level intervention when needed. During virtual visits and between encounters, maintain situational awareness of member health status and proactively flag emerging clinical risks before they require emergency intervention.

Facilitate Cross-Disciplinary Care Coordination Across the Pod.
Coordinate seamlessly with the members PCP, APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure each member's care is cohesive and accountable across every role in the pod. Serve as the central communication point for caregivers - ensuring updates, care plan changes, and clinical concerns are shared promptly and accurately with all pod members and external care partners.

Support HEDIS, Quality, and Care Gap Closure.
Participate in care gap closure activities - facilitating outreach for abnormal lab values, overdue preventive services, and HEDIS measure gaps in coordination with the Care Coordinator and APC. Support the pod's quality performance targets by ensuring members receive timely follow-up, preventive care reminders, and education that closes documented care gaps.

Manage Chronic Condition Care Pathways and Guideline-Directed Care Delivery.

Proactively manage members with chronic conditions (e.g., heart failure, COPD, diabetes, CKD, and other high-risk comorbidities) through ongoing monitoring and structured care pathway oversight - ensuring care aligns with evidence-based, guideline-directed medical therapy (GDMT) and best-practice protocols. Identify changes in clinical status, adherence gaps, and emerging risks through regular outreach and review of clinical indicators. Partner with member PCPs, APCs and the pod to optimize treatment plans, escalate opportunities for medication adjustments or further evaluation, and ensure timely follow-up on labs, diagnostics, and specialty care. Reinforce chronic disease education with members and caregivers, including medication adherence, symptom management, lifestyle modifications, and recognition of escalation triggers. Maintain updated care plans and coordinate across disciplines to support stabilization, prevent exacerbations, and reduce avoidable utilization while advancing quality and outcome goals.

Document All Clinical Interactions Accurately and Timely in Athena.
Maintain accurate, complete, and timely documentation of all member interactions, care coordination activities, medication reconciliations, escalations, and care plan updates in Athena within established timeframes. Ensure documentation supports HCC coding accuracy, care continuity, and compliance with CMS and organizational standards.

Other duties and projects not listed above

Supervisory Responsibilities:

This role is an individual contributor with no direct reports or supervisory authority. The CCM RN leads through clinical expertise and care coordination within the pod - all formal people management matters are owned by the Manager, Clinical Operations.

Job Requirements:

Experience:

Required:

• Minimum 3 years of clinical RN experience - with direct patient care in complex care, care management, transitions of care, case management, palliative care/hospice, acute care, or a related clinical setting
• Demonstrated experience managing medically complex, high-risk patient populations - including chronic disease management, medication reconciliation, and care transition coordination
• Prior experience in a Medicare Advantage, managed care, home-based care, or value-based care environment with working knowledge of HEDIS, HCC coding, and care gap management
• Experience working in a telehealth or virtual care delivery model - with proficiency in virtual member engagement and remote clinical monitoring
• Demonstrated ability to coordinate care across multiple disciplines and communicate effectively with clinical and non-clinical team members

Preferred:

• Experience with Athena EMR and TalkDesk or equivalent virtual engagement platform
• Background in population health, care management programs, or complex case management for Medicare populations

Education:

Required:

• Associate Degree in Nursing (ADN) - Bachelor of Science in Nursing (BSN) strongly preferred
• Active, unrestricted Registered Nurse (RN) license in applicable state(s)
• Multi-state licensure preferred given fully virtual, multi-market model
• Current BLS certification

Preferred:

• BSN or higher from an accredited nursing program
• Case Management Certification (CCM) or equivalent care management credential

Training:

Required:

• Demonstrated proficiency with telehealth delivery platforms
• Working knowledge of Medicare Advantage benefits, care coordination protocols, and transitions of care standards

Preferred:

• Formal training in motivational interviewing, health coaching, or complex care management
• HEDIS documentation and quality measure training
• Transitions of care certification or equivalent training

Specialized Skills:

Required:

• Complex Care Coordination and Member Journey Management (Advanced): Ability to own and manage the full care journey for high-acuity Medicare Advantage members - maintaining consistent engagement, coordinating across disciplines, and proactively addressing clinical and social needs before they escalate.
• Transitions of Care and Medication Reconciliation (Advanced): Expert proficiency in post-discharge care coordination - including medication reconciliation, care plan updates, follow-up outreach, and cross-disciplinary communication that reduces readmission risk and ensures safe care transitions.
• Clinical Assessment and Escalation Judgment (Advanced): Ability to assess member clinical status through virtual encounters - identifying changes in condition, triaging urgency, and escalating to the APC or RMO with the right clinical context and timing to support effective provider-level decision-making.
• Telehealth and Virtual Member Engagement (Advanced): Proficiency in delivering clinical care coordination entirely through virtual channels - conducting effective telehealth encounters, building member trust remotely, and maintaining engagement cadence for a complex, high-risk population.
• Athena EMR and Clinical Documentation (Advanced): Advanced proficiency in Athena documentation - ensuring all care coordination activities, medication reconciliations, escalations, and care plan changes are documented accurately, completely, and within required timeframes to support HCC coding, care continuity, and compliance.
• Cross-Disciplinary Communication and Pod Collaboration (Advanced): Ability to serve as the central coordination hub of a multi-disciplinary care pod - communicating clearly and proactively with APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure cohesive, accountable care delivery for every assigned member.
• HEDIS and Quality Measure Awareness (Intermediate): Working knowledge of HEDIS measures relevant to the Medicare Advantage population - with the ability to identify and facilitate care gap closure activities in coordination with the APC and Care Coordinator.

Preferred:

Licensure:

Required:

• Active, unrestricted RN license in applicable state(s)
• BLS certification

Preferred:

• Multi-state licensure preferred
• Certified Case Manager (CCM)
• ACLS certification

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $85,696.00 - $128,543.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.