Registered Nurse Care Manager

Blue Zones Health is creating a Well-Being Services Organization built around a complete and integrated understanding of each member's health, needs, goals, and circumstances. Clinical Management plays a critical role in ensuring members—particularly those with chronic conditions, complex medical needs, and recent transitions of care—receive coordinated, proactive, and personalized support.

The RN Care Manager provides comprehensive clinical care management for Blue Zones Health members, with a primary focus on chronic disease management, high- and rising-risk populations, Special Needs Plan (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 across the healthcare continuum, and serves as a clinical liaison among members, caregivers, providers, specialists, community organizations, and internal interdisciplinary teams.

Working closely with Population Health and Well-Being Services, the RN Care Manager integrates clinical care coordination with lifestyle medicine, self-management strategies, community resources, and holistic approaches that support improved health outcomes, reduced avoidable utilization, and long-term member well-being.

Partner with the Population Health team to identify high- and rising-risk members using available data, clinical information, utilization patterns, and risk stratification tools

Conduct comprehensive clinical assessments through telehealth and telephonic outreach, evaluating medical, functional, psychosocial, environmental, and behavioral factors affecting member health

Perform medication reconciliation and identify potential barriers to medication adherence, treatment plans, and disease self-management

Develop, implement, and continuously monitor individualized care plans in partnership with members, caregivers, providers, and the interdisciplinary care team

Support members and caregivers in understanding chronic conditions, treatment plans, preventive care needs, medication adherence, and lifestyle modifications

Identify barriers to care and develop practical strategies to support member engagement and successful self-management

Support implementation and execution of SNP-specific Model of Care requirements, including health risk assessments, individualized care plans, care coordination, and interdisciplinary care processes

Ensure assigned members receive appropriate care management activities consistent with SNP requirements and organizational standards

Participate in interdisciplinary care team meetings and case discussions involving complex and high-risk members

Support SNP-related quality improvement activities and ongoing efforts to strengthen care coordination and member outcomes

Maintain awareness of applicable regulatory, health plan, NCQA, CMS, and organizational requirements relevant to care management activities

Ensure required assessments, care plans, interventions, and follow-up activities are completed and documented within established timeframes

Coordinate transitions of care for members discharged from inpatient hospitals, skilled nursing facilities, emergency departments, and other care settings

Conduct timely post-discharge outreach to assess member needs, identify barriers, and support continuity of care

Coordinate follow-up appointments, referrals, medication reconciliation, durable medical equipment, home health services, and other post-discharge needs

Develop and execute discharge support plans designed to reduce gaps in care and prevent avoidable readmissions

Identify members at elevated risk for readmission and coordinate appropriate clinical, social, and community-based interventions

Maintain communication with members, caregivers, providers, and care teams throughout the transition process

Serve as a clinical liaison among primary care providers, specialists, facilities, caregivers, community agencies, and internal clinical teams

Coordinate appropriate services and referrals to ensure members receive timely and connected care

Facilitate warm handoffs between clinical teams, Well-Being Services, community resources, and other appropriate support services

Participate in interdisciplinary huddles, case conferences, and care team meetings for complex members

Escalate clinical concerns and barriers appropriately to providers and clinical leadership

Build strong collaborative relationships across internal and external care partners to reduce fragmentation and improve the member experience

Partner closely with Well-Being Services to integrate lifestyle medicine and holistic well-being resources into the care management model

Identify members who may benefit from Well-Being Services programming, lifestyle support, community-based resources, or other non-clinical interventions

Initiate appropriate referrals and warm handoffs to Well-Being Services

Collaborate with Well-Being Services team members to support member engagement, self-management, and achievement of individualized health goals

Incorporate appropriate lifestyle, behavioral, social, and environmental considerations into care management planning

Support an integrated approach that combines clinical care coordination with sustainable strategies that improve long-term health and well-being

Help establish effective workflows between RN Care Management and Well-Being Services to ensure members experience coordinated and seamless support

Assess members for social determinants of health and other non-clinical barriers that may affect health outcomes and access to care

Identify needs related to transportation, food access, housing, caregiver support, financial barriers, and other social or environmental factors

Connect members with appropriate community-based programs, services, and resources

Coordinate with internal teams and external organizations to support resolution of identified barriers

Track resource referrals and follow-up to help ensure members are successfully connected to appropriate services

Incorporate identified social and environmental needs into individualized care plans when appropriate

Accurately document all care management assessments, encounters, interventions, care coordination activities, and care plan updates in the EMR and applicable care management systems

Maintain complete, timely, and clinically appropriate documentation supporting member care and organizational requirements

Ensure care plans are regularly reviewed and updated based on changes in member condition, needs, goals, utilization, and engagement

Document referrals, transitions of care, interdisciplinary coordination, and follow-up activities

Maintain appropriate confidentiality and compliance with applicable privacy, security, and organizational standards

Use care management platforms, telehealth tools, and other technology effectively to support efficient and coordinated member care

Monitor clinical outcomes, utilization patterns, readmission rates, care plan completion, member engagement, and other applicable performance measures

Track performance against established care management, SNP, quality, and organizational goals

Identify patterns, barriers, and opportunities to improve member outcomes and care delivery

Participate in quality improvement initiatives designed to strengthen care management workflows, transitions of care, and member experience

Use clinical and operational data to identify opportunities for earlier intervention and more effective care coordination

Share relevant insights and trends with clinical leadership and interdisciplinary partners

Contribute to a culture of accountability, continuous improvement, and member-centered care

Build trusted relationships with members and caregivers through consistent, compassionate, and clinically appropriate engagement

Support members in understanding their health conditions and navigating complex healthcare systems

Encourage active participation in care planning and shared decision-making

Provide education and coaching that supports disease self-management, preventive care, medication adherence, and healthy lifestyle behaviors

Identify barriers to engagement and adapt outreach approaches to meet individual member needs

Help members access the appropriate level of clinical, social, community, and well-being support