RN Care Manager: Chronic Disease & Transitions

Blue Zones Health; California (MO); On-site; USD 110,000 - 120,000; Full time

Job summary

Blue Zones Health is seeking an experienced RN Care Manager to provide comprehensive clinical care management for members, with a primary focus on chronic disease management, SNP Model of Care requirements, and transitions of care following inpatient, skilled nursing facility, and emergency department encounters.

The RN Care Manager conducts comprehensive clinical assessments, develops and monitors individualized care plans, coordinates services, and serves as a clinical liaison among members,

Qualifications

• Active and unrestricted RN license in California.
• 3+ years in care management or related clinical settings.
• Experience with SNP Model of Care and transitions of care.
• Strong communication and collaboration across teams.
• Experience with EMRs and telehealth platforms.

Responsibilities

• Provide comprehensive clinical care management for Blue Zones Health members, focusing on chronic disease management, SNP Model of Care requirements, and transitions of care.
• Conduct comprehensive clinical assessments through telehealth and telephone outreach.
• Develop, implement, and monitor individualized care plans in partnership with members and care teams.
• Coordinate services across the healthcare continuum and serve as a clinical liaison among members, caregivers, providers, and interdisciplinary teams.
• Support lifestyle medicine, self-management, and community resources to improve health outcomes.

Skills

Care coordination

Clinical assessment

Discharge planning

Communication

EMR usage

Telehealth

Interdisciplinary collaboration

Education

Bachelor of Science in Nursing

Tools

EMR systems

Care management platforms

Telehealth tools

Job description

Blue Zones Health is seeking an experienced RN Care Manager to provide comprehensive clinical care management for members, with a primary focus on chronic disease management, SNP Model of Care requirements, and transitions of care following inpatient, skilled nursing facility, and emergency department encounters.

The RN Care Manager conducts comprehensive clinical assessments, develops and monitors individualized care plans, coordinates services, and serves as a clinical liaison among members,