RN Case Manager – D-SNP / Medicare Advantage

Our client, a IT Services and Consulting company, is looking for a RN Case Manager – D-SNP / Medicare Advantage for their Remote location.
 
Responsibilities:

• The D-SNP Case Manager is responsible for coordinating care and providing telephonic case management services for Dual Eligible Special Needs Plan (D-SNP) members, with a primary focus on Transition of Care (TOC) activities, care coordination, member engagement, and closure of quality and STAR measure gaps.
• This role serves as a clinical resource for members transitioning across care settings and works collaboratively with providers, caregivers, community resources, and internal teams to improve health outcomes, support continuity of care, and enhance member experience.
• The D-SNP Case Manager conducts comprehensive clinical assessments, develops individualized care plans, performs targeted member outreach, and facilitates interventions designed to address medical, behavioral, social, and preventive care needs
• Serve as a member of a multidisciplinary care team supporting Dual Eligible Special Needs Plan (D-SNP) members through care coordination, transition management, member engagement, and quality improvement activities.
• Conduct comprehensive clinical, psychosocial, functional, and social determinants of health (SDOH) assessments to identify member needs, barriers to care, and opportunities for intervention.
• Manage Transition of Care (TOC) activities for members following discharge from inpatient, skilled nursing facility, rehabilitation, emergency department, or other healthcare settings, including 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 that address medical, behavioral health, functional, social, and preventive care needs.
• Conduct proactive outbound member outreach to identify and close gaps in care 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, facilitate appointments or screenings, and remove barriers to care.
• Educate members regarding their health conditions, treatment plans, preventive care recommendations, available benefits, and community resources to support self-management and improved outcomes.
• Monitor member progress toward established goals through ongoing assessments, follow-up outreach, evaluation of outcomes, and care plan updates based on member acuity and identified needs.
• Identify members with complex medical, behavioral, social, or functional needs and facilitate appropriate referrals to case management, behavioral health, community-based organizations, or other support services.
• Support the 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, as applicable.
• Utilize available clinical, utilization, and quality data to identify opportunities for improved member outcomes, care coordination, quality performance, and plan performance.
• Ensure all activities are performed in 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 all member interactions, assessments, interventions, care plans, referrals, follow-up activities, and outcomes in designated systems.
• Participate in quality improvement initiatives, audits, care management programs, and departmental projects designed to improve member outcomes, Model of Care performance, operational effectiveness, and plan performance

• NC license or compact license allowed to practice in NC
• 3 Years of Experience

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities