Nurse Case Manager, High Risk

Position Summary : The High Risk Nurse Case Manager provides intensive care management and coordination services for high-risk members who require enhanced intervention beyond traditional care management models. This role focuses on complex, high-utilization members with significant clinical, psychosocial, and transitional care needs to improve clinical outcomes, reduce avoidable readmissions, and ensure safe transitions across the continuum of care.

The High Risk Nurse Case Manager collaborates with interdisciplinary teams, providers, facilities, and community resources to develop and implement comprehensive, member-centered care plans and ensure timely access to appropriate services.

Program Goals

• Engage and actively case manage Round Table members through intensive outreach and intervention
• Reduce avoidable hospital readmissions and emergency department utilization
• Improve clinical outcomes for high-risk and complex members
• Effectively manage transitions of care between hospital, home, and post‑acute settings
• Ensure timely and accurate medication reconciliation and medication management

Essential Position Functions/Responsibilities:

• Receives referrals through internal systems, risk stratification tools, claims data, inpatient teams, and provider referrals based on established criteria.
• Reviews Round Table census daily and prioritizes members requiring intervention.
• Conducts comprehensive review of member medical records, utilization patterns, and risk factors.
• Identifies members eligible for Round Table enrollment and additional care management programs, including state and federal programs.
• Coordinates discharge planning with inpatient teams, providers, and facilities.
• Engages members and caregivers telephonically and/or in person to introduce care management services and establish ongoing engagement.
• Arranges or performs home assessments prior to discharge, when appropriate, to evaluate home safety, support systems, and equipment needs.
• Identifies home risk factors, transitional barriers, and social determinants impacting care.
• Facilitates transitions between acute care, skilled nursing facilities, inpatient rehabilitation, long‑term acute care, and home settings.
• Conducts post‑discharge outreach within two (2) business days and maintains ongoing follow‑up as indicated.
• Assists in development and implementation of comprehensive, member‑centered care plans addressing clinical, psychosocial, financial, and environmental needs.
• Reviews member response to treatment and updates care plans accordingly.
• Advises on transition to the least restrictive, medically appropriate level of care.
• Coordinates services to ensure seamless transitions across healthcare settings.
• Interfaces with providers, facilities, home health agencies, and community resources to coordinate services.
• Facilitates referrals for home health, durable medical equipment, outpatient services, and community‑based programs.
• Coordinates NP home visits and collaborates with interdisciplinary team members to address barriers to care.
• Reviews support systems including family, private caregivers, and community resources.
• Ensures medication reconciliation within 48–72 hours following discharge.
• Coordinates follow‑up appointments with primary care providers, specialists, and therapy services.
• Assists with transportation coordination and access to follow‑up care.
• Reviews additional medical records to ensure care plan adherence and clinical improvement.
• Participates in Round Table rounds, campus rounds, and interdisciplinary case conferences.
• Identifies gaps in care and recommends additional services as indicated, including:
  • Home health and therapy services
  • Hospice or palliative care
  • Behavioral health services
  • Wound care services
  • Outpatient rehabilitation
  • Personal care services
  • Community‑based programs (Meals on Wheels, adult day care, etc.)
  • Assisted living or alternative placement
• Supports reduction of avoidable utilization and improvement of quality outcomes.
• Maintains accurate and timely documentation in care management systems.
• Performs preservice reviews for Round Table members as required.
• Utilizes independent judgment to prioritize workload and manage multiple high‑risk cases.
• Participates in departmental initiatives, process improvement efforts, and special projects.
• Maintains confidentiality and compliance with HIPAA and organizational policies.
• Participates in special projects, process improvement initiatives, and departmental activities as assigned.

Qualification Requirements:
Skills, Knowledge, Abilities

• Excellent written and verbal communication skills
• Strong clinical assessment and critical thinking abilities
• Ability to work independently and manage complex cases
• Strong organizational and time management skills
• Ability to prioritize and manage multiple demands simultaneously
• Interdisciplinary team collaboration skills
• Knowledge of Managed Medicare and Medicaid reimbursement guidelines
• Knowledge of home health and post‑acute care services
• Familiarity with InterQual and Milliman criteria preferred
• Knowledge of NCQA and URAC standards preferred
• Proficiency in Microsoft Office applications including Word, Excel, and Outlook

Training/Education:

• Active Registered Nurse (RN) license required
• Bachelor of Science in Nursing (BSN) preferred
• Case Management Certification (CCM or equivalent) preferred

Experience:

• Minimum 2 years of insurance, MSO, care management, or high‑intensity case management experience preferred
• Minimum 4 years of home health or complex case management experience preferred
• Experience working with high‑risk and geriatric populations preferred
• Experience with transitions of care and post‑acute coordination preferred

Base Compensation; $95,000 - $105,000 annually

Equal Employment Opportunity Statement:
HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Job Disclaimer:
The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.