RN Complex Case Manager — Care Coordination & Outcomes

Harris Health; Houston (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

Community Health Choice, Inc. seeks a Complex Case Manager (RN) to identify, monitor, and coordinate care for members with chronic or complex conditions across care settings. The CCM collaborates with PCPs, specialists, and other providers to develop and implement individualized plans.

The role requires Texas RN licensure, 5 years of acute care experience, and CCM certification or progress toward it within 18 months. Strong communication and data-entry skills are essential for success.

Qualifications

• RN license in Texas, unrestricted.
• 5 years clinical experience in an acute care setting preferred; 2 years insurance related experience in a managed care environment.
• CCM certification required or must be completed within 18 months of employment.
• Proficient with Microsoft Office.

Responsibilities

• Identify, monitor, manage, and evaluate health services for members with chronic or medically complex conditions in acute and non-acute settings.
• Coordinate care with the member, PCP, specialists and other providers.
• Identify the most appropriate therapeutic intervention to maximize clinical outcomes.
• Conduct telephonic assessments and create individualized care plans with discharge needs.
• Authorize services for active members across all levels of care (outpatient, inpatient, transitional).
• Ensure data entry of authorizations and initiate approval processes using established criteria and procedures.
• Refer to community health workers and disease management teams as needed.
• Collaborate with medical directors and refer requests not meeting medical necessity criteria.
• Initiate single case agreements or letters of agreement for out-of-network providers.
• Meet performance/quality metrics and regulatory requirements.

Skills

Verbal communication

Analytical thinking

Education

Registered Nurse (RN) license in Texas

BSN preferred

CCM certification or must obtain within 18 months

Tools

Microsoft Word

Job description

Community Health Choice, Inc. seeks a Complex Case Manager (RN) to identify, monitor, and coordinate care for members with chronic or complex conditions across care settings. The CCM collaborates with PCPs, specialists, and other providers to develop and implement individualized plans.

The role requires Texas RN licensure, 5 years of acute care experience, and CCM certification or progress toward it within 18 months. Strong communication and data-entry skills are essential for success.