Accountabilities:

• Conduct comprehensive intake assessments with members and families and develop individualized care plans that reflect clinical, financial, social, and other relevant circumstances.
• Coordinate care with Interdisciplinary Care Team (ICT) members, primary care providers, specialists, caregivers, and ancillary providers to ensure continuity and appropriate follow-through.
• Serve as the primary care management contact for members and caregivers, helping them understand benefits, access in-network providers, and connect with community resources.
• Support members during transitions of care and conduct virtual face-to-face visits when needed to address coordination and care needs.
• Provide education, resources, and support that strengthen member self-management skills and promote improved health outcomes and quality of life.
• Review and evaluate Health Risk Assessment (HRA) information and other member data to identify needs, barriers, and opportunities for targeted programs and services.
• Manage and triage member self-referrals to appropriate care management programs and collaborate with other care management professionals to coordinate services.
• Participate in care management, case management, and quality committees and contribute to program development, implementation, oversight, and delegation activities.
• Review medical records and documentation as needed, investigate potential quality-of-care concerns, and support initiatives designed to protect member health and safety.
• Contribute to audits, quarterly reporting, and oversight activities while ensuring alignment with CMS SNP Model of Care requirements, NCQA standards, Medicare Advantage regulations, and applicable contractual requirements.
• Identify opportunities to improve care management processes, resources, and member outcomes while maintaining accurate documentation and meeting required deliverables.

Requirements:

• Current Registered Nurse (RN) license in the state where services are provided, or an active multistate RN license through the enhanced Nurse Licensure Compact (eNLC).
• At least 3 years of clinical healthcare experience.
• At least 1 year of experience in care management, case management, or population health.
• Bachelor’s degree in Nursing is preferred; an Associate of Science in Nursing (ASN) degree or nursing diploma is also considered.
• Experience working with Medicare, Medicaid, and/or Special Needs Plan (SNP) populations is preferred.
• At least 1 year of SNP care management experience is preferred.
• Working knowledge of CMS regulatory and contractual requirements, Medicare Advantage, NCQA accreditation standards, disease management, utilization management, care management, and discharge planning.
• Strong written and verbal communication skills, with the ability to collaborate effectively with members, caregivers, providers, and multidisciplinary teams.
• Strong problem-solving and organizational skills, including the ability to manage competing priorities and consistently meet deadlines and deliverables.
• Exceptional attention to detail and the ability to maintain accurate member records and documentation.
• Proficiency with Microsoft Office applications.
• Ability to remain effective and professional in stressful or demanding working conditions.
• Ability to perform the physical requirements of the role, including standing and walking for extended periods, frequent bending or stretching, and lifting or pushing items within the stated limits.

Benefits:

• Full-time, 40-hour-per-week position.
• Remote work arrangement.
• Exempt employment status.
• Opportunity to make a direct impact on the health outcomes and quality of life of SNP members.
• High-visibility role within a medical management and care coordination environment.
• Opportunity to collaborate with interdisciplinary clinical teams, providers, caregivers, and community resources.
• Professional exposure to Medicare Advantage, SNP Model of Care, CMS requirements, and NCQA standards.
• Comprehensive role encompassing clinical care coordination, quality improvement, regulatory compliance, and population health initiatives.