Case Manager RN

DOCTORS HEALTHCARE PLANS, INC.•Coral Gables, FL

About The Position

The Nurse Case Manager coordinates care activities for assigned patients, supporting appropriate use of resources, service delivery, and compliance with medical regimens. The role serves as a system navigator and point of contact for patients in managed care programs, helping them understand benefits and access care. It includes assessment and reassessment, care planning, medication reconciliation after facility discharges, monitoring care outcomes, and coordinating communication among patients, families, physicians, facilities, and other care team members. The Case Manager also helps patients address medical, psychosocial, financial, and social barriers; connects them with relevant community and internal or external resources; supports referrals and benefit coordination; and advocates for accessible, timely care. The role contributes to program outreach, data collection, reporting, chart review, case conferences, and the maintenance of clinical standards and evidence-based practices.

Requirements

RN or LPN licensure required.
Ability to take action to solve problems and exercise sound judgment.
Strong oral and written communication skills, including the ability to interact with all organizational levels and external contacts.
Strong organizational and time-management skills.

Nice To Haves

Managed care experience preferred.
Bilingual English and Spanish preferred.

Responsibilities

Perform and coordinate initial patient assessments and ongoing reassessments.
Document patient case information in a database and maintain accurate, timely, review-ready records.
Perform chart reviews and audits monthly or as needed.
Participate in monthly case conferences and provide information relevant to patient needs and goals.
Partner with the Program Director to develop and review individualized coordination-of-care plans.
Coordinate treatment plans with physicians and advocate for patients as needed.
Help patients access entitlements, benefits, resources, information, referrals, and psychosocial support.
Assist with data collection and reporting for funding sources, including statistical information.
Act as a liaison among patients, primary care providers, specialists, and other care team members.
Participate in outreach activities and conduct member outreach by phone, mail, or other communication methods to encourage program engagement.
Recommend program or service changes to address community service gaps.
Complete medication reconciliation after facility discharges, including hospital, long-term acute care, and skilled nursing facility discharges, based on member needs.
Follow up on member needs involving durable medical equipment and home health care, and offer relevant community support when available.
Facilitate communication among members, families, healthcare facilities, physicians, and other applicable providers to improve care coordination.
Identify high-risk members who may need complex case management and coordinate interventions with the primary care physician and care team; respect members' opportunity to opt in or out of care management programs.
Establish and maintain clinical standards, including preventive health and clinical practice guidelines.
Refer members to internal and external programs and coordinate benefits, including transportation, ambulance approvals, DME, and home health care services.
Steer members toward participating and preferred providers and assist with access to Medicaid resources when applicable.
Apply clinical guidelines, policies, and benefit plans using professional judgment and critical thinking to determine level of care, service intensity, length of stay, and place of service.
Identify existing and potential problems and take action to prevent or address them.
Develop care plans based on assessments, with objectives, goals, and interventions tailored to member needs.
Identify appropriate healthcare resources based on medical needs, including evaluating contracts and negotiating with facilities or vendors.
Work with members, families, providers, and the care team to develop care plans that support clinical outcomes while maximizing member benefits.
Apply evidence-based guidelines when available and use community resources and care alternatives effectively.
Implement and coordinate interventions that support achievement of case management goals.
Continually reassess services and care-plan goals, monitor information from relevant sources, and take action to improve outcomes.
Help reduce cultural and healthcare-system barriers, promote timely treatment, empower patients to become self-advocates, and help them navigate managed care.
Assist the SNP Case Manager Director with member HRA outreach calls.
Work with patients by phone to review and remind them about their care plans and progress toward care management goals.
Collaborate with other service providers on care coordination and case management activities.
Perform other duties as assigned or required by the manager or supervisor.