Complex Case Manager

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.

Responsibilities

• 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.
• 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.
• Perform other duties as assigned.
• Understanding of NCQA Care Management standards, care coordination best practices, and applicable state and federal regulatory requirements.

Requirements

• Qualifications Current, active, unrestricted Registered Nurse (RN) license required.
• 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.
• 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.

About

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.