RN Care Manager: Chronic Disease & Transitions

OUR PHILOSOPHY

Blue Zones Health is creating a Well-Being Services Organization built around a complete and integrated understanding of each member's health, needs, goals, and circumstances. Clinical Management plays a critical role in ensuring members—particularly those with chronic conditions, complex medical needs, and recent transitions of care—receive coordinated, proactive, and personalized support. Description

OUR PHILOSOPHY

Blue Zones Health is creating a Well-Being Services Organization built around a complete and integrated understanding of each member's health, needs, goals, and circumstances. Clinical Management plays a critical role in ensuring members—particularly those with chronic conditions, complex medical needs, and recent transitions of care—receive coordinated, proactive, and personalized support. Position Summary The RN Care Manager provides comprehensive clinical care management for Blue Zones Health members, with a primary focus on chronic disease management, high- and rising-risk populations, Special Needs Plan (SNP) Model of Care requirements, and transitions of care following inpatient, skilled nursing facility, and emergency department encounters. The RN Care Manager conducts comprehensive clinical assessments, develops and monitors individualized care plans, coordinates services across the healthcare continuum, and serves as a clinical liaison among members, caregivers, providers, specialists, community organizations, and internal interdisciplinary teams. Working closely with Population Health and Well-Being Services, the RN Care Manager integrates clinical care coordination with lifestyle medicine, self-management strategies, community resources, and holistic approaches that support improved health outcomes, reduced avoidable utilization, and long-term member well-being. Budgeted Compensation: $110,000-$120,000 Key Responsibilities Chronic Disease & Population Health Management Partner with the Population Health team to identify high- and rising-risk members using available data, clinical information, utilization patterns, and risk stratification tools Conduct comprehensive clinical assessments through telehealth and telephonic outreach, evaluating medical, functional, psychosocial, environmental, and behavioral factors affecting member health Perform medication reconciliation and identify potential barriers to medication adherence, treatment plans, and disease self-management Develop, implement, and continuously monitor individualized care plans in partnership with members, caregivers, providers, and the interdisciplinary care team Support members and caregivers in understanding chronic conditions, treatment plans, preventive care needs, medication adherence, and lifestyle modifications Identify barriers to care and develop practical strategies to support member engagement and successful self-management SNP Model of Care & Regulatory Compliance Support implementation and execution of SNP-specific Model of Care requirements, including health risk assessments, individualized care plans, care coordination, and interdisciplinary care processes Ensure assigned members receive appropriate care management activities consistent with SNP requirements and organizational standards Participate in interdisciplinary care team meetings and case discussions involving complex and high-risk members Support SNP-related quality improvement activities and ongoing efforts to strengthen care coordination and member outcomes Maintain awareness of applicable regulatory, health plan, NCQA, CMS, and organizational requirements relevant to care management activities Ensure required assessments, care plans, interventions, and follow-up activities are completed and documented within established timeframes Transitions of Care & Discharge Planning Coordinate transitions of care for members discharged from inpatient hospitals, skilled nursing facilities, emergency departments, and other care settings Conduct timely post-discharge outreach to assess member needs, identify barriers, and support continuity of care Coordinate follow-up appointments, referrals, medication reconciliation, durable medical equipment, home health services, and other post-discharge needs Develop and execute discharge support plans designed to reduce gaps in care and prevent avoidable readmissions Identify members at elevated risk for readmission and coordinate appropriate clinical, social, and community-based interventions Maintain communication with members, caregivers, providers, and care teams throughout the transition process Care Coordination & Interdisciplinary Collaboration Serve as a clinical liaison among primary care providers, specialists, facilities, caregivers, community agencies, and internal clinical teams Coordinate appropriate services and referrals to ensure members receive timely and connected care Facilitate warm handoffs between clinical teams, Well-Being Services, community resources, and other appropriate support services Participate in interdisciplinary huddles, case conferences, and care team meetings for complex members Escalate clinical concerns and barriers appropriately to providers and clinical leadership Build strong collaborative relationships across internal and external care partners to reduce fragmentation and improve the member experience Well-Being Services & Lifestyle Medicine Partnership Partner closely with Well-Being Services to integrate lifestyle medicine and holistic well-being resources into the care management model Identify members who may benefit from Well-Being Services programming, lifestyle support, community-based resources, or other non-clinical interventions Initiate appropriate referrals and warm handoffs to Well-Being Services Collaborate with Well-Being Services team members to support member engagement, self-management, and achievement of individualized health goals Incorporate appropriate lifestyle, behavioral, social, and environmental considerations into care management planning Support an integrated approach that combines clinical care coordination with sustainable strategies that improve long-term health and well-being Help establish effective workflows between RN Care Management and Well-Being Services to ensure members experience coordinated and seamless support Social Determinants of Health & Community Resource Coordination Assess members for social determinants of health and other non-clinical barriers that may affect health outcomes and access to care Identify needs related to transportation, food access, housing, caregiver support, financial barriers, and other social or environmental factors Connect members with appropriate community-based programs, services, and resources Coordinate with internal teams and external organizations to support resolution of identified barriers Track resource referrals and follow-up to help ensure members are successfully connected to appropriate services Incorporate identified social and environmental needs into individualized care plans when appropriate Documentation & Clinical Care Management Systems Accurately document all care management assessments, encounters, interventions, care coordination activities, and care plan updates in the EMR and applicable care management systems Maintain complete, timely, and clinically appropriate documentation supporting member care and organizational requirements Ensure care plans are regularly reviewed and updated based on changes in member condition, needs, goals, utilization, and engagement Document referrals, transitions of care, interdisciplinary coordination, and follow-up activities Maintain appropriate confidentiality and compliance with applicable privacy, security, and organizational standards Use care management platforms, telehealth tools, and other technology effectively to support efficient and coordinated member care Clinical Outcomes, Performance & Quality Improvement Monitor clinical outcomes, utilization patterns, readmission rates, care plan completion, member engagement, and other applicable performance measures Track performance against established care management, SNP, quality, and organizational goals Identify patterns, barriers, and opportunities to improve member outcomes and care delivery Participate in quality improvement initiatives designed to strengthen care management workflows, transitions of care, and member experience Use clinical and operational data to identify opportunities for earlier intervention and more effective care coordination Share relevant insights and trends with clinical leadership and interdisciplinary partners Contribute to a culture of accountability, continuous improvement, and member-centered care Member Engagement & Clinical Support Build trusted relationships with members and caregivers through consistent, compassionate, and clinically appropriate engagement Support members in understanding their health conditions and navigating complex healthcare systems Encourage active participation in care planning and shared decision-making Provide education and coaching that supports disease self-management, preventive care, medication adherence, and healthy lifestyle behaviors Identify barriers to engagement and adapt outreach approaches to meet individual member needs Help members access the appropriate level of clinical, social, community, and well-being support Requirements

REQUIRED QUALIFICATIONS

Active and unrestricted Registered Nurse (RN) license in California Minimum of 3+ years of experience in care management, chronic disease management, utilization management, transitions of care, inpatient care management, or a related clinical setting Demonstrated experience conducting comprehensive clinical assessments and developing individualized care plans Experience coordinating care for members with complex medical, functional, psychosocial, and social needs Experience supporting transitions of care, discharge planning, post-discharge outreach, and readmission prevention Hands-on experience with SNP Model of Care requirements and interdisciplinary care team coordination Strong clinical judgment and ability to independently assess, prioritize, and manage complex member needs Experience performing medication reconciliation and identifying barriers to treatment adherence and care engagement Strong verbal and written communication skills with the ability to collaborate effectively across clinical and non-clinical teams Experience using EMRs, care management platforms, telehealth tools, and other clinical technology Strong organizational, problem-solving, and independent work capabilities Preferred Qualifications Bachelor of Science in Nursing (BSN) Certified Case Manager (CCM) or other relevant care management certification Experience working in Medicare Advantage, Special Needs Plans, value-based care, managed care, health plans, IPAs, or medical groups Experience working with population health programs and risk stratification models Familiarity with HEDIS, NCQA, CMS, and other healthcare quality and performance measures Experience integrating social determinants of health and community resource coordination into clinical care management Experience collaborating with interdisciplinary teams across clinical, behavioral, social, and community-based services Experience supporting lifestyle medicine, preventive health, or holistic approaches to member well-being Experience working in a hybrid, telephonic, or telehealth-based care management environment #J-18808-Ljbffr Blue Zones Health