Job Title: Case Manager

Job Description

The Case Manager coordinates and manages a panel of members with complex medical needs, ensuring safe transitions of care, reducing avoidable readmissions, and supporting members in achieving their health goals. This role focuses on comprehensive case management, including outreach, assessment, care planning, and ongoing follow-up, while collaborating closely with healthcare providers, internal teams, and community resources.

Responsibilities

• Identify complex cases based on established enrollment criteria and prioritize members for case management services.
• Monitor and manage an assigned member caseload, performing routine follow-ups with each patient to assess progress and needs.
• Conduct patient follow-ups telephonically, in the primary care provider’s office, in the patient’s home, or in other appropriate settings based on the patient’s condition and needs.
• Contact members after hospital discharge and after completion of the transitional nurse visit to discuss program details, offer enrollment, and initiate the enrollment process.
• Ensure all documentation of member interactions, assessments, and interventions is thorough, accurate, and completed within established timeframes.
• Document actions taken to prevent hospital readmission and other transitions of care, ensuring clear rationale and outcomes are recorded.
• Complete required Health Risk Assessment (HRA) outreach within 30 days of member eligibility or upload from the health plan.
• Develop individualized plans of care with goals that are Specific, Measurable, Attainable, Realistic, and Time Bound (S.M.A.R.T.), reflecting each member’s unique needs and priorities.
• Submit care plans to the registered nurse for review and approval, and update the plan of care as members’ health conditions and needs change.
• Upload pertinent medical records and documents to the member’s electronic medical/health record (EMR/EHR) to ensure accurate and up-to-date information.
• Collaborate with healthcare providers and staff involved in the member’s care to optimize continuity of care, minimize unnecessary resource utilization, reduce hospitalizations, and support member adherence to treatment plans.
• Educate members on available organizational resources and community services, helping them understand and access appropriate support.
• Mail welcome packets to members, including resource booklet information and other relevant program materials.
• Obtain updated orders from primary care providers or other applicable healthcare providers to initiate services not included in the initial discharge plan.
• Submit all orders with pertinent supporting documentation to the case management support team for timely submission to providers’ offices before or at the time of patient appointments.
• Attend care coordination interdisciplinary team (IDT) meetings and staff meetings to discuss cases, share updates, and support collaborative care planning.
• Collaborate with the scheduling team to ensure members receive timely and appropriate appointments and services.
• Assist with processing referrals to expedite care, optimize health outcomes, and prevent exacerbation of disease processes.
• Submit shared drive communication forms and advance directives to the appropriate staff in accordance with departmental policies and procedures.
• Stay current with hospital discharge planning expectations and interventions, ensuring outreach and follow-up are timely and aligned with departmental standards.
• Maintain professional communication with members, families, providers, and internal teams to support a positive care experience and effective case management.

Essential Skills

• Graduate of an accredited Licensed Vocational Nursing (LVN) program.
• Current LVN license in good standing.
• Minimum of 2 years of clinical nursing experience, or at least 1 year of case management experience.
• Experience in acute care or hospital settings.
• Knowledge of medical terminology and clinical documentation standards.
• Ability to perform comprehensive assessments and develop individualized plans of care.
• Proficiency using Microsoft Office applications, including Word, Outlook, Excel, and PowerPoint.
• Ability to work effectively with electronic medical/health records (EMR/EHR) and related software.
• Strong organizational skills with the ability to manage a caseload and meet established timeframes.
• Effective verbal and written communication skills for interacting with members, providers, and colleagues.
• Ability to work independently and as part of an interdi