Care Manager, RN

Role Overview

• Conduct comprehensive health assessments, including medical, behavioral, and social determinants of health (SDOH)
• Develop, implement, and evaluate individualized care plans based on member needs, goals, and risk level
• Coordinate care across multiple settings, including inpatient, outpatient, and community-based services
• Facilitate transitions of care, including hospital discharge planning and post-discharge follow-up
• Utilize clinical expertise to identify gaps in care, potential risks, and opportunities for early intervention
• Monitor member progress and adjust care plans accordingly
• Provide education to members and caregivers regarding disease management, medications, and treatment plans
• Apply evidence-based guidelines and best practices in care management
• Support appropriate utilization of healthcare services to ensure cost-effective care delivery
• Collaborate with utilization management teams to reduce avoidable hospitalizations and emergency department visits. Identify high-risk members and implement strategies to improve outcomes and reduce healthcare costs
• Partner with physicians, specialists, behavioral health providers, and community agencies to coordinate care
• Serve as a liaison between members, providers, and health plan resources
• Participate in interdisciplinary team meetings and case conferences
• Maintain effective communication to ensure continuity of care
• Ensure timely and accurate documentation in accordance with regulatory, CMS, and organizational requirements
• Support quality improvement initiatives, including HEDIS, STAR ratings, and other performance measures
• Maintain compliance with accreditation standards and internal policies
• Conduct outreach to engage members in care management programs
• Promote self-management and adherence to treatment plans. Address barriers to care, including social, economic, and cultural factors

Requirements

• Bachelor of Science in Nursing (BSN) preferred; Associate degree in Nursing required
• At least 2 years of clinical nursing experience (case management, acute care, or managed care preferred)
• Certifications & Licensure Active, unrestricted Registered Nurse (RN) license
• ACM (Accredited Case Manager) certification required or must be obtained within a specified timeframe
• CCM (Certified Case Manager) may be considered in lieu of or in addition to ACM (depending on organizational requirements)
• Strong knowledge of care management principles, utilization management, and population health
• Understanding of regulatory standards (CMS, NCQA, etc.). Ability to assess and manage complex clinical and psychosocial situations
• Excellent communication, collaboration, and critical-thinking skills
• Proficiency in electronic health records (EHR) and care management documentation systems
• Ability to manage multiple priorities in a fast-paced environment
• Experience in care coordination, discharge planning, or population health strongly preferred

Benefits

• This role follows a hybrid work structure where the expectation is to work on the field and at home on a weekly basis. The home office is located at 1301 Atwood Avenue, Suite 206N, Johnston, RI 02919.
• This position requires up occasional travel for onsite visits or team meetings.
• Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.