Case Manager II, RN

Job Description

Remote in California only Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth. Who Are We? ✨ Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. Why Join Us? We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. Job Summary The experienced Case Manager II – RN is responsible for managing a caseload of moderate to high-complexity members, including those with multiple chronic conditions, behavioral health needs, and SDOH barriers. Functions independently with minimal supervision and serves as a clinical resource to CM I staff. Functions & Job Responsibilities All responsibilities of Case Manager I, plus: · Conducts comprehensive assessments within regulatory timelines. · Identifies members appropriate for case management using established criteria and clinical guidance. · Develops and implements individualized care plans in collaboration with the member, caregiver, and interdisciplinary team. · Performs telephonic and virtual outreach; face-to-face visits as required. · Monitors care plan progress and documents interventions timely and accurately. · Coordinates medical, behavioral health, and community-based services. · Provide clinical education and self-management coaching. · Addresses barriers to care including transportation, medication access, and social determinants. · Manages high-risk, high-utilization, and complex members. · Leads interdisciplinary care team (ICT) conferences for assigned members. · Performs advanced clinical assessments and identifies gaps in care. · Serves as primary Transitions of Care (TOC) lead for assigned caseload. · Interprets risk stratification data (ACG, HRA, quality metrics) to prioritize outreach. · Identifies quality gap opportunities and collaborates with Quality to support closure. · Mentors and provides guidance to Case Manager I staff. · Assists with audit preparation and regulatory compliance initiatives. · Identifies trends impacting quality, utilization, and member outcomes. · Reviews risk stratification data (ACG, HRA, utilization reports) to prioritize outreach. · Participates in quality improvement and performance initiatives. · Mentors and provides guidance to Case Manager I staff. · Serves as lead for designated CM programs (e.g., TOC, SNP compliance tracking, CCM workflow). · Supports development and refinement of care management workflows. · Monitors adherence to assigned program timelines and documentation standards. · Provides subject matter expertise during cross-departmental meetings. · Identifies operational improvement opportunities and escalates system gaps. · Additional duties, as assigned. Qualifications Education and Experience Licensures and Certifications · Active, unrestricted California RN license. · 3–5 years of case management or managed care experience. · Experience managing high-acuity populations. · Strong critical thinking and problem-solving skills. · Certified Case Manager (CCM) preferred · Certified Managed Care Nurse (CMCN) preferred Skills · Effective communication skills including verbal and written · Ability to manage time effectively, understand directions, and work independently in a fast-paced environment · Demonstrated flexibility, organization, and self-motivation · Highly adaptable to change · Bilingual in Mandarin/Cantonese, Vietnamese, Spanish, or Korean, preferred Wage Range: $88,355.00 - $100,000 per year Physical & Working Environment. Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation: • Must be able to travel when needed or required • Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking) • Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs. Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business. Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. #LI-Hybrid