Nurse Case Manager - Chronic Disease Management Specialist

DOCS Management Services•Coos Bay, OR

10d•$35 - $51•Hybrid

About The Position

We are currently hiring a Nurse Case Manager - Chronic Disease Management Specialist . If you are an experienced nurse, skilled in case management, an effective motivational interviewer, and value being part of a team that makes a difference, you may be the right person for the position! Apply today! JOB SPECIFICATIONS Classification: Non-exempt | Status: Part-time, Monday - Friday, generally 8am to 5pm, Pacific Time, with flexibility for member needs (occasional evenings/weekends) Salary: $35.29 - $51.38/hourly Department: Utilization Review | Work Location: Hybrid Reports to: Director of Medical Services | Supervision Exercised: Non-supervisory Job Purpose: Chronic Disease Management Specialist The Certified Case Manager (CCM) - Chronic Disease Management Specialist provides comprehensive care coordination and management for members with chronic conditions (e.g., congestive heart failure, diabetes, COPD). This role focuses on improving health outcomes, reducing hospitalizations, and enhancing quality of life through individualized care plans, member education, and collaboration with healthcare teams. The CCM utilizes evidence-based practices and certification skills to optimize resource utilization and support health plan goals. Collaborates with interdisciplinary teams, providers, and community resources to ensure members receive person-centered, culturally responsive, and cost-effective care.

Requirements

Minimum Associate Degree in Nursing required; Bachelor’s degree preferred
Certified Case Manager (CCM) credential through the Commission for Case Manager Certification (CCMC) strongly preferred
Minimum 3–5 years’ experience in case management, chronic disease management, or a related healthcare role; experience in a managed care or health plan setting preferred
Knowledge of evidence-based practices and requirements to evaluate existing standards and implement new procedures
Understanding of principles of health care of populations
Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics
Understanding of basic concepts of managed care
Critical attention to detail for accuracy and timeliness
High degree of initiative, judgment, discretion, and decision-making
Patient-centered and culturally responsive approach
Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health conditions to determine best outcomes for members
Proficient in electronic health record (EHR) systems and case management software (e.g., Optum tools)
Knowledge of chronic disease management guidelines and reimbursement models (e.g., Medicare, Medicaid)
Strong interpersonal and communication skills for effective member advocacy and interdisciplinary collaboration
Commitment to quality improvement, equity, and population health outcomes
Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
Proficient in Microsoft Office Suite and Windows Operating System (OS)
Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
Ability to manage multiple priorities and caseloads effectively
Excellent people skills and friendly demeanor
Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
Attention to detail and organization skills
Ability to handle stress and sensitive situations effectively while projecting a professional attitude
Ability to communicate professionally, both conversing and written
Ability to work with diverse populations and interact with people of differing personalities and backgrounds
Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
Ability to organize and work in a sensitive manner with people from other cultures
Poised; maintains composure and sense of purpose

Nice To Haves

Additional certifications (e.g., Certified Diabetes Educator) a plus

Responsibilities

Conduct initial and ongoing assessments of member health status, including medical history, functional ability, psychosocial needs, and risk factors
Develop and update individualized care plans based on clinical guidelines (e.g., AHA, ADA) and member-centered goals
Coordinate with interdisciplinary teams (e.g., physicians, nurses, social workers, pharmacists) to ensure smooth care transitions and continuity of care
Support care transitions, including post-discharge planning and follow-up within 48–72 hours
Implement disease-specific interventions such as medication adherence support, lifestyle coaching, and dietary education
Monitor member progress through routine check-ins (home visits, telephonic, telehealth, etc.) and update care plans based on reassessment
Educate members and caregivers on symptom management, self-care, and emergency response plans
Review healthcare utilization data to identify cost-effective care opportunities and reduce over-utilization
Advocate for appropriate services in alignment with health plan policies and medical necessity guidelines
Document assessments, care plans, interventions, and outcomes in member records
Provide data and insights to support quality improvement initiatives and performance tracking
Link members to appropriate community and support resources (e.g., transportation, palliative care, meal programs)
Use technology (e.g., remote monitoring tools) to enhance care management and communication
Participate in quality and organizational process improvement activities when requested
Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
Advance personal knowledge base by pursuing continuing education to enhance professional competence
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
Represent organization at meetings and conferences as applicable