The Role
Manages a complex member caseload through comprehensive clinical assessments, individualized care planning, care coordination, transitions of care, member and caregiver education, outreach, and follow-up. Identifies care gaps and barriers, collaborates with interdisciplinary teams, documents activities, supports quality improvement, and ensures compliance with NCQA, HIPAA, and regulatory requirements.
Summary Generated by Built In
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
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.
- Perform other duties as assigned.
- 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.
- 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.
- 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.
Skills Required
- Current, active, unrestricted Registered Nurse license
- Compact multistate nursing licensure
- Willingness and ability to obtain New York State RN licensure within 30 days of hire if not currently licensed in New York
- At least two years of nursing experience in care management, population health, managed care, utilization management, or a related clinical setting
- Clinical knowledge of 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 and applicable state and federal regulations
- Strong clinical assessment, medical record review, critical thinking, and problem-solving skills
- Ability to identify care gaps, barriers to care, and opportunities to improve outcomes
- Excellent verbal and written communication skills
- Ability to prioritize workload, manage multiple assignments, and work independently
- Proficiency in Microsoft Office applications and electronic medical record, case management, and database systems
- Commitment to member confidentiality and HIPAA compliance
- Ability to adapt to changing priorities and support quality and accreditation initiatives
- Bachelor of Science in Nursing
- Certified Case Manager, Accredited Case Manager, or relevant case management certification
- Experience managing members with complex or chronic medical conditions
- Experience in managed care, Medicare, Medicaid, commercial health plans, or population health programs
- Experience with NCQA-accredited health plans and NCQA Care Management standards
- Knowledge of evidence-based care management, motivational interviewing, and member engagement strategies
- Bilingual Spanish-speaking skills
Am I A Good Fit?
Get Personalized Job Insights.
Our AI-powered fit analysis compares your resume with a job listing so you know if your skills & experience align.
Success! Refresh the page to see how your skills align with this role.
The Company
What We Do
Brighton Health Plan Solutions (BHPS) is a health care enablement company that is transforming the way health care is accessed and delivered. Our innovative, customizable, sustainable solutions encourage patient activation and improve the quality of care — all at lower cost. We effect impactful change for self-funded plan sponsors, health systems, and TPAs through our extensive health care expertise: •Decades of health plan design and health plan management experience •Proprietary MagnaCare, Create®, and Casualty provider networks •Strong provider relationships •Cutting-edge, white-labeled technology platform that enhances the experience for providers, plan purchasers and health care consumers
