Primary responsibilities include: Responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits; conducts gap in care management for quality programs Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangements, as permissible Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting and company policies and procedures May assist in problem solving with provider, claims or service issues Preferred: Private duty nursing experience and knowledgeable with ventilators in a facility or home Education Associates or Bachelors Degree in Nursing Certification/Licensure Registered Nurse License (RN) - Nursing License - Compact/Multi-State License required.