Assess members with complex medical and psychosocial needs, develop and monitor individualized care plans, and coordinate services across providers and community resources. Document case management activities, support quality and regulatory requirements, and collaborate with interdisciplinary teams to improve outcomes and reduce avoidable utilization.
About The Role The Complex Case Manager maintains a caseload of members with complex medical and care coordination needs and reports directly to the Supervisor, Case Management. In addition, the role maintains a dotted-line relationship to the Senior Director, Case Management (RN) for clinical guidance, nursing practice standards, and case management program oversight. This position is also responsible for assuring appropriate systems are in place to collect and report program activities and outcomes for case management programs. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities, and activities may change, or new ones may be assigned at any time with or without notice. *This is a Remote role.
Primary Responsibilities
Conduct comprehensive assessments to identify complex medical, psychosocial, functional, utilization, and care coordination needs.
Develop, implement, monitor, and update individualized, member-centered care plans in collaboration with members, caregivers, providers, and interdisciplinary teams.
Coordinate care across the healthcare continuum to promote quality outcomes, appropriate utilization, member engagement, and cost-effective care.
Provide education and coaching to members and caregivers regarding health conditions, treatment plans, medications, preventive care, and self-management strategies.
Identify and address barriers to care, treatment adherence, health equity, and achievement of care plan goals.
Facilitate transitions of care and support timely access to medical and community-based services.
Perform ongoing outreach, monitoring, reassessment, and follow-up to evaluate progress toward goals and modify care plans as needed.
Collaborate with members, caregivers, providers, and community resources to support coordination of care and continuity of services.
Utilize evidence-based guidelines, clinical criteria, nursing judgment, and care management best practices to support clinical decision-making and interventions.
Identify gaps in care, emerging risks, and opportunities for intervention to improve member outcomes and reduce avoidable utilization.
Present complex cases during interdisciplinary case reviews and participate in collaborative care planning and problem-solving activities.
Collaborate with Utilization Management, Population Health, Medical Directors, and other internal and external stakeholders to support integrated care delivery.
Maintain accurate, timely, and complete documentation of assessments, care plans, interventions, member progress, and coordination activities in accordance with organizational, regulatory, and accreditation standards.
Ensure compliance with NCQA Care Management standards, HIPAA requirements, applicable state and federal regulations, and organizational policies and procedures.
Participate in quality improvement initiatives, audits, accreditation activities, performance improvement projects, and ongoing professional development.
Compact (Multistate) Nursing Licensure is required. New York State RN licensure is highly preferred. Candidates who do not currently hold a New York State RN license must be willing and able to obtain NYS licensure within thirty (30) days of hire. The incumbent must maintain all licenses and credentials required to perform the responsibilities of the position.
Bachelor of Science in Nursing (BSN) preferred; Associate Degree in Nursing (ADN) with relevant experience considered.
Minimum two (2) years of nursing experience in care management, population health, managed care, utilization management, or a related clinical setting; experience managing members with complex or chronic medical conditions preferred.
Demonstrated clinical knowledge in comprehensive assessment, care planning, chronic and complex condition management, and care coordination.
Experience conducting comprehensive clinical assessments and developing individualized, member-centered care plans.
Knowledge of complex case management principles, healthcare delivery systems, and community resources.
Understanding of NCQA Care Management standards, care coordination best practices, and applicable state and federal regulatory requirements.
Strong clinical assessment, medical record review, critical thinking, and problem-solving skills.
Ability to identify care gaps, barriers to care, and opportunities to improve member outcomes.
Excellent verbal and written communication skills, with the ability to effectively engage members, caregivers, providers, and interdisciplinary teams.
Demonstrated ability to prioritize workload, manage multiple assignments, and work independently with minimal supervision.
Proficiency in Microsoft Office applications and experience working within electronic medical record, case management, and database systems.
Commitment to maintaining member confidentiality and compliance with HIPAA and other applicable regulations.
Ability to adapt to changing priorities and support organizational goals, quality initiatives, and accreditation requirements.
Preferred Qualifications
Bachelor of Science in Nursing (BSN).
Certified Case Manager (CCM), Accredited Case Manager (ACM), or other relevant case management certification preferred.
Experience in managed care, Medicare, Medicaid, commercial health plans, or population health programs.
Experience working within an NCQA-accredited health plan and applying NCQA Care Management standards, including assessment, care planning, care coordination, transitions of care, and ongoing member monitoring, strongly preferred.
Knowledge of evidence-based care management practices, motivational interviewing, and member engagement strategies.
Strong organizational, analytical, and decision-making skills.
Demonstrated ability to collaborate effectively across multidisciplinary teams and with community-based providers and resources.
Self-motivated, proactive, and comfortable working in a fast-paced environment with competing priorities.
Knowledge of healthcare regulations, quality improvement methodologies, and managed care requirements.
Bilingual Spanish-speaking skills preferred but not required.
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