RN, Care Manager

Job Summary:

The RN Care Manager provides clinical leadership and decision-making for care management in accordance with NCQA standards, CMS guidelines, health plan contracts, and company policy. The RN is responsible for conducting comprehensive clinical assessments, medication reconciliation, evaluating data gathered by LVNs, and analyzing health plan–completed Health Risk Assessments (HRAs) to design and approve individualized S.M.A.R.T. care plans. Operating as the clinical escalation lead, the RN provides operational guidance and oversight for LVN team members, leads Interdisciplinary Team (IDT) reviews, and collaborates with multidisciplinary providers to manage complex chronic conditions, prevent unnecessary hospitalizations, and ensure safe transitions of care.

• Provide clinical direction and oversight for LVN case management activities. Synthesize clinical, psychosocial, and functional data gathered by LVNs, along with health plan–completed HRAs, to establish comprehensive clinical baseline profiles for complex members.
• Conduct independent clinical assessments and develop, evaluate, and formally complete individualized S.M.A.R.T. (Specific, Measurable, Attainable, Realistic, Time-Bound) care plans, establishing appropriate goals and evidence-based interventions.
• Periodically review and modify care plans based on member progress, clinical changes, or input from LVN follow-ups, providing required signoffs and documentation in the EMR.
• Manage high-acuity member caseloads—including multi-morbid conditions such as CHF, CAD, CKD, Diabetes, COPD, Cancer, and Dementia—monitoring outcomes and adjusting interventions to optimize health stability.
• Perform post-discharge clinical assessments following transitional nurse calls for complex members, ensuring safe care handoffs, medication reconciliation, and readmission-prevention strategies.
• Lead and participate in Interdisciplinary Team (IDT) meetings with PCPs, medical directors, and specialists to present complex cases and establish collaborative, cross-functional care strategies.
• Evaluate requests for medical necessity, authorization compliance, and service utilization using approved clinical guidelines (e.g., Milliman/InterQual), ensuring care matches payor and regulatory standards.
• Recommend and coordinate specialized support services (e.g., LCSW, Respiratory Therapy, Home Health) and facilitate provider orders and referrals to address care gaps and social determinants of health.
• Maintain thorough clinical documentation of assessments, care plans, IDT decisions, and health plan communications in the EMR within strict regulatory timeframes.
• Perform all other duties as assigned.

The pay range for this position at commencement of employment is expected to be between $63.86 and $70.74 hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.