RN Case Manager

BrightonOne•Boston, MA

20d•$95,000 - $107,500•Hybrid

About The Position

The RN Case Manager provides telephonic case management to US Family Health Plan (USFHP) members with chronic, complex, or high-risk conditions. The role is a key point of contact for internal and external stakeholders, ensuring member care management aligns with BrightonOne's mission and regulatory guidelines. The RN independently conducts comprehensive assessments, develops and executes individualized care plans, and coordinates care across providers, settings, and community resources to improve clinical outcomes, close care gaps, and enhance the member experience for veterans and military-connected families.

Requirements

Associate’s degree in Nursing (ADN) required.
2 or more years of clinical nursing experience.
At least 1 or more years of case management experience, preferably in a managed care or health plan setting.
Active, unrestricted RN license in Massachusetts.
Certified Case Manager (CCM) or Certified Behavioral Health Case Manager (CBHCM) certification required; candidates who do not hold certification at hire must obtain it within 3 years of hire.
Strong clinical assessment, care planning, and communication skills.
Ability to work independently and manage a caseload, with strong organizational, time-management, and prioritization skills.
Working knowledge of utilization review, disease management, and care management principles, including evidence-based clinical criteria.
Demonstrated ability to assess, evaluate, and interpret medical information and care plans.
Strong clinical nursing knowledge and ability to identify quality-of-care concerns.
High level of understanding of community resources and healthcare delivery systems.
Proficient with electronic health records and healthcare technologies, and in Microsoft Office Suite.
Excellent interpersonal and advocacy skills, with the ability to build rapport with members, families, and providers.
Proficiency in motivational interviewing and health-coaching techniques.
Knowledge of behavioral health conditions and trauma-informed care.
Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.
Candidates must be authorized to work in the United States without sponsorship now or in the future.

Nice To Haves

Bachelor's degree in Nursing (BSN) preferred.
Experience coordinating Applied Behavior Analysis (ABA) services, or with TRICARE’s Extended Care Health Option (ECHO) program, is a plus but not required.
Familiarity with military culture, the unique needs of veterans and military-connected families, and TRICARE/USFHP is a plus but not required.

Responsibilities

Identify and engage eligible members through referrals, risk stratification, and outreach; obtain member consent and enroll members in case management.
Conduct comprehensive assessments across clinical, behavioral, functional, medication, and psychosocial domains using standardized tools and screenings.
Develop, implement, and continually update individualized, member-centered care plans with measurable, time-bound goals and scheduled reassessment.
Apply motivational interviewing and health-coaching techniques to strengthen engagement, adherence, and self-management.
Screen for behavioral health and safety risks, including depression, substance use, and suicide risk, and connect members to crisis and behavioral health services as needed.
Manage members across chronic and complex conditions and high-risk/high-cost cohorts.
Support medication management and adherence in partnership with pharmacy, including medication reconciliation and resolution of gaps or barriers.
Coordinate services, durable medical equipment, home health, and specialty resources for members with catastrophic or multi-comorbid conditions.
Collaborate with PCPs, specialists, utilization management, referral management, pharmacy, and behavioral health to align care.
Support safe transitions of care and proactively address gaps to reduce avoidable admissions and ER use.
Close HEDIS and preventive-care gaps and link members to community, veteran-specific, and social-determinant resources.
Educate members and caregivers on conditions, treatment plans, and benefits, and advocate for members as they navigate the health system.
Maintain accurate, timely documentation in the care management platform meeting TRICARE/USFHP and NCQA/accreditation standards.
Track goal attainment, engagement, and outcome/quality metrics; identify and escalate high-acuity members and safety concerns per protocol.
Determine readiness for case closure based on goal attainment, and complete closure documentation and member notification.
Participate in interdisciplinary case rounds, quality improvement initiatives, and documentation audits.
Maintain member confidentiality in compliance with HIPAA and organizational privacy policies.