Job Title: RN-Case Manager
Location: Remote 
Duration: 5 months with possible extension

Job Description / Responsibilities

Coordinate care and provide telephonic case management services for Dual Eligible Special Needs Plan (D-SNP) members.
Focus on Transition of Care (TOC), care coordination, member engagement, and closure of quality and STAR measure gaps.
Serve as a clinical resource for members transitioning across care settings.
Conduct comprehensive clinical, psychosocial, functional, and Social Determinants of Health (SDOH) assessments.
Manage Transition of Care activities following discharge from inpatient, skilled nursing facility, rehabilitation, emergency department, or other healthcare settings.
Conduct timely telephonic outreach to members and/or caregivers to assess needs, reinforce discharge instructions, identify barriers, and facilitate follow-up care.
Develop, implement, and maintain individualized, member-centric care plans addressing medical, behavioral health, functional, social, and preventive care needs.
Conduct proactive outbound member outreach to identify and close gaps related to Medicare STAR measures, HEDIS measures, preventive screenings, chronic disease management, medication adherence, and other quality initiatives.
Collaborate with providers, care teams, caregivers, community partners, and internal departments to coordinate services and remove barriers to care.
Educate members regarding health conditions, treatment plans, preventive care recommendations, available benefits, and community resources.
Monitor member progress through ongoing assessments, follow-up outreach, evaluation of outcomes, and care plan updates.
Identify members with complex medical, behavioral, social, or functional needs and facilitate appropriate referrals.
Support completion and documentation of Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), Interdisciplinary Care Team (ICT) activities, and other D-SNP Model of Care requirements.
Utilize clinical, utilization, and quality data to identify opportunities for improved member outcomes, care coordination, quality performance, and plan performance.
Ensure compliance with CMS regulations, Medicare Advantage and D-SNP requirements, NCQA standards, organizational policies, and applicable regulatory requirements.
Maintain accurate, complete, and timely documentation of member interactions, assessments, interventions, care plans, referrals, follow-up activities, and outcomes.
Participate in quality improvement initiatives, audits, care management programs, and departmental projects.

Must Have:

Active NC RN license or compact RN license allowing practice in NC.
3+ years of nursing experience.
Experience with case management and care coordination.
Experience with Transition of Care (TOC).
Strong clinical assessment and member engagement skills.
Experience with care plans, HRA, ICP, and/or ICT activities.
Knowledge of Medicare Advantage, D-SNP, STAR/HEDIS measures, CMS, and NCQA requirements preferred.

  
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $60.71/hr - $61.75/hr.