Nurse Case Manager: Health Equity & Care Coordination

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommunityCare HMO Inc. is seeking a Population Health Nurse Case Manager to assess member needs, coordinate care, and promote improved health outcomes within PHM.

You will work with members, caregivers, providers, and interdisciplinary teams to develop individualized care plans and address barriers to care. Responsibilities include identifying high-risk members, completing assessments, coordinating medical, behavioral health, pharmacy, and community services, supporting transitions of care,

Qualifications

• RN license in good standing in Oklahoma.
• Graduation from an accredited School of Nursing.
• Minimum four years of clinical nursing experience in an acute care setting.
• Discharge planning or case management experience preferred.

Responsibilities

• Identify and engage members with complex conditions using referrals and data.
• Complete assessments and develop individualized care plans within nursing scope.
• Provide ongoing outreach to monitor progress and update plans.
• Coordinate medical, behavioral health, pharmacy, and community services to support member goals.
• Support transitions of care with timely follow-up, discharge coordination, and connection to needed services.
• Educate members and caregivers on chronic condition management, preventive care, and treatment adherence.
• Address social needs and barriers involving transportation, affordability, access, and health literacy.
• Participate in interdisciplinary care meetings and communicate care plans to members and appropriate providers.
• Maintain timely documentation and support quality improvement, accreditation, and regulatory requirements.
• Perform other job-related duties as required or assigned.

Skills

Managed care

Case management

Chronic conditions

Community resources

Clinical judgment

Communication

Collaboration

MS Office

Care management systems

Education

RN license (Oklahoma)

Nursing degree

CCM certification preferred

Tools

EMR/EHR systems

Microsoft Office

Job description

CommunityCare HMO Inc. is seeking a Population Health Nurse Case Manager to assess member needs, coordinate care, and promote improved health outcomes within PHM.

You will work with members, caregivers, providers, and interdisciplinary teams to develop individualized care plans and address barriers to care. Responsibilities include identifying high-risk members, completing assessments, coordinating medical, behavioral health, pharmacy, and community services, supporting transitions of care,