Job Description Summary

The Clinical Case Manager, RN at CareMore Health is responsible for coordinating and managing quality, cost-effective care for members with complex medical and psychosocial needs. Working within an interdisciplinary care team, this role supports CareMore’s value-based care model by proactively managing high-risk patient populations, improving clinical outcomes, and helping reduce avoidable hospitalizations and emergency department utilization.

The Clinical Case Manager, RN collaborates closely with providers, patients, families, and community partners to assess needs, develop individualized care plans, and facilitate services across the continuum of care. This role plays a critical part in supporting patients with chronic and complex conditions while ensuring appropriate utilization of healthcare resources.

How will you make an impact & Requirements

Key Responsibilities

• Clinical Case Management
• Assess, plan, facilitate, coordinate, monitor, and evaluate services to meet the healthcare needs of members, particularly those with complex or high-risk conditions.
• Develop and implement comprehensive clinical case management plans tailored to each patient’s medical, behavioral, and social needs.
• Collaborate with physicians, advanced practice providers, and interdisciplinary care teams to support evidence-based care and effective disease management.
• Monitor patient progress and revise care plans as needed to address changes in clinical status or care needs.
• Identify and address barriers to care including social determinants of health, treatment adherence challenges, or gaps in services.
• Analyze patient variances from the established care plan and initiate appropriate interventions to resolve issues and improve outcomes.

• Value-Based Care & Population Health Management
• Support CareMore’s value-based care model by focusing on improved outcomes, care coordination, and appropriate utilization of healthcare services.
• Manage high-risk or medically complex patients with chronic conditions such as heart failure, diabetes, COPD, and other conditions requiring ongoing care coordination.
• Collaborate with care teams to proactively manage patients who are at risk for hospitalization or complications.
• Promote preventive care, chronic disease management, and patient engagement strategies that improve long-term health outcomes.

• Care Coordination & Member Support
• Support members and their representatives regarding care needs, care transitions, and changes in health status.
• Serve as a liaison between patients, providers, and care teams to facilitate coordinated care delivery.
• Coordinate services across multiple care settings including primary care, specialty care, hospitals, skilled nursing facilities, home health agencies, and community-based resources.
• Provide education and support to patients and families regarding treatment plans, medications, and self-management strategies.
• Support smooth transitions between care settings to reduce complications, readmissions, and unnecessary healthcare utilization.

• Documentation & Compliance
• Maintain accurate, complete, and timely documentation in accordance with organizational policies and regulatory requirements.
• Ensure compliance with applicable clinical protocols, utilization management guidelines, and federal and state regulations.
• Maintain strict confidentiality of member information in accordance with HIPAA and other regulatory standards.

Compensation Range:

$81,492.00 to $122,238.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.