Remote Rn Case Manager Jobs in Spring Hill, FL (NOW HIRING)

The Case Manager is responsible for providing comprehensive case management, complex case management, and disease management services to health plan members. This position promotes quality, cost-effective healthcare outcomes through assessment, care coordination, member education, advocacy, and collaboration with providers, caregivers, and community resources. The Case Manager works with members across the continuum of care to improve health outcomes, reduce gaps in care, address social determinants of health, and support members in achieving their healthcare goals.

Essential Functions:

Case Management

· Conduct comprehensive assessments to identify members' medical, behavioral, psychosocial, functional, and environmental needs.

· Develop, implement, and monitor individualized care plans based on identified needs and member-centered goals.

· Coordinate healthcare services among primary care providers, specialists, hospitals, rehabilitation facilities, and community agencies.

· Facilitate transitions of care following hospital admissions, emergency department visits, and post-acute care services.

· Monitor member progress and evaluate the effectiveness of interventions and care plans.

· Assist members in accessing covered benefits, community resources, and supportive services.

· Educate members and caregivers regarding treatment plans, medications, preventive care, and available resources.

· Maintain timely, accurate, and complete documentation in accordance with regulatory and organizational requirements.

· Participate in interdisciplinary care team meetings and case conferences.

Complex Case Management

· Manage high-risk members with multiple chronic conditions, catastrophic illnesses, behavioral health conditions, or significant social and environmental challenges.

· Perform comprehensive clinical assessments to identify complex healthcare needs and risk factors.

· Develop and implement comprehensive care management plans focused on improving health outcomes and quality of life.

· Coordinate multidisciplinary care involving physicians, specialists, behavioral health providers, pharmacists, social workers, and community partners.

· Identify and address barriers to care, including transportation, housing instability, food insecurity, financial concerns, caregiver support needs, and access to services.

· Facilitate continuity of care across multiple healthcare settings and providers.

· Monitor utilization patterns and implement interventions to reduce preventable hospitalizations, readmissions, and emergency department utilization.

· Engage members and caregivers in shared decision-making and long-term care planning.

· Reassess member needs regularly and modify care plans based on changing clinical conditions and circumstances.

· Participate in interdisciplinary rounds and utilization management activities as needed.

Disease Management

· Identify, assess, and engage members with chronic health conditions such as diabetes, hypertension, asthma, COPD, heart failure, coronary artery disease, and other targeted diagnoses.

· Conduct disease-specific assessments and identify gaps in care.

· Educate members regarding disease processes, treatment plans, medications, symptom management, and healthy lifestyle practices.

· Promote evidence-based clinical guidelines and self-management strategies.

· Support medication adherence and preventive care initiatives.

· Monitor clinical outcomes, laboratory values, and member progress toward disease management goals.

· Collaborate with healthcare providers to address gaps in care and improve clinical outcomes.

· Encourage preventive screenings, immunizations, and routine follow-up care.

· Track and document interventions and outcomes in accordance with disease management program requirements.

· Support quality improvement initiatives and performance measures related to chronic disease management.

Additional Responsibilities

· Collaborate with internal departments including Utilization Management, Quality Improvement, Behavioral Health, Pharmacy, and Provider Relations.

· Ensure compliance with all federal, state, accreditation, and health plan requirements, including HIPAA regulations.

· Support organizational initiatives focused on population health management and value-based care.

· Participate in ongoing training, education, and professional development activities.

· Perform other duties as assigned.

Competencies:

• Clinical assessment and care planning
• Care coordination and resource management
• Member advocacy and engagement
• Population health management
• Chronic disease management
• Critical thinking and problem solving
• Interdisciplinary collaboration
• Cultural competence and sensitivity
• Time management and organization
• Documentation and regulatory compliance

Required Education and Experience:

• Bilingual in English and Spanish
• Active, unrestricted Massachusetts clinical license such as:
• Registered Nurse (RN)
• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Other applicable clinical license as required by state regulations
• Certified Case Manager (CCM) certification.
• Minimum of three (3) years of experience in case management, care coordination, disease management, utilization management, managed care, or related healthcare settings in the health plan environment or managed care.
• Experience supporting Medicare, Medicaid, Dual Eligible, Commercial, or Special Needs populations.
• Knowledge of healthcare delivery systems, insurance benefits, community resources, and care coordination principles.
• Strong assessment, critical thinking, problem-solving, and clinical decision-making skills.
• Excellent communication, organizational, and interpersonal skills.
• Proficiency with electronic health records, care management platforms, and Microsoft Office applications.

Preferred education, certifications and/or experience:

• Knowledge of HEDIS, STAR Ratings, NCQA standards, and population health management programs.

Physical Requirements/Work environment: 

• Remote role with occasional travel (Less than 5%)
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.
• Must have home office, mobile phone, computer with security requirements met.
• Internet Speed Minimum of 100 Mbps download and 10–20 Mbps upload
• Typing/data entry of 30 WPM

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without advanced notice.