RN CARE MANAGER - COMPLEX CARE & HIGH UTILIZER MANAGEMENT

The RN Care Manager – Complex Care & High Utilizer Management is responsible for the comprehensive management of participants who exhibit high utilization of outpatient services, are at high risk for readmission, hospitalization, or ED visits, or present with complex behavioral health needs and chronic conditions such as COPD, Heart Failure, and Diabetes. This role provides advanced clinical oversight, risk stratification, and proactive outreach to ensure participants receive timely, coordinated, and appropriate care. The RN Care Manager – Complex Care & High Utilizer Management collaborates closely with medical providers, behavioral health specialists, and operational leaders to develop and implement strategies that reduce avoidable utilization, strengthen chronic disease management, and enhance participant experience. The RN Care Manager – Complex Care & High Utilizer Management also ensures that referrals—particularly those related to high-risk and complex participants—are clinically appropriate, timely, and aligned with evidence-based interventions for chronic disease care pathways.

Chronic Disease Management: Deliver ongoing care, support, and health education to participants with chronic illnesses including COPD, Diabetes, Heart Failure, cardiovascular disease, and degenerative neurological or musculoskeletal disorders. Facilitate and enable engagement with the CL provider and IDT Design and lead the implementation of care pathways and clinical protocols to streamline the management of the most common chronic illnesses. Develop and implement individualized chronic disease action plans to prevent avoidable ED visits, hospital readmissions, and disease exacerbations in collaboration with TOC and IDT. Conduct clinical reviews using evidence-based criteria to ensure appropriateness of care for chronic disease–related needs. High Utilizer Oversight (Outpatient, Inpatient & ED): Lead clinical management of participants identified as high utilizers of outpatient care or at elevated risk for hospital or ED use. Perform risk stratification emphasizing chronic disease burden and complex behavioral health conditions such as COPD, CHF, Diabetes, and psychiatric comorbidities. Monitor utilization patterns and proactively engage participants to reduce unnecessary, repetitive, or avoidable service use Collaborate with behavioral health staff to address psychosocial, psychiatric, or adherence related barriers that contribute to high utilization. Referral & Utilization Review: Oversee the referral process for high-risk and complex participants to ensure clinical appropriateness and timeliness. Collect and evaluate clinical documentation supporting medical necessity for specialty services, chronic disease care, and behavioral health interventions. Prioritize urgent referrals and coordinate follow-through for participants at highest medical risk. Support participants in navigating the healthcare system and reinforce chronic-condition self-management practices. Respond to participant concerns related to care access, delays, or coordination and resolve barriers in real time. Care Coordination & Communication: Work closely with CenterLight physicians, behavioral health teams, and external providers to ensure cohesive, risk reducing care coordination Maintain current knowledge of CenterLight's provider network, including behavioral health and chronic disease specialties such as COPD, CHF, and Diabetes care. Communicate care trends, system changes, and clinical insights to the CMO and IDT. Serve as the Clinical Programs’ subject matter expert, coordinating with TOC, Social Work Care Managers, Clinical Review Specialists, and the IDT for high-risk or complex cases. Partner with TOC on safe discharge planning and transitions to reduce readmissions. Quality & Performance Improvement: Conduct prospective, concurrent, and retrospective clinical reviews related to chronic disease and complex care management. Apply evidence-based guidelines to determine medical necessity for participants with frequent ED visits, behavioral health complexity, or chronic disease complications. Participate in quality improvement initiatives, including inter‑rater reliability testing. Support HR‑HI provider panel updates and contribute clinical insights to enhance risk reduction and chronic disease control. Perform other duties as assigned.