Case Manager - Capitated Business

Position Summary: The Value Based Care R.N. for Capitated Programs is responsible for coordinating and managing patient care within capitated and risk-based contract environments. This role focuses on ensuring quality, cost-effective, and clinically appropriate care for members by partnering with our MSO partners to conduct assessments, develop care plans, coordinate services, and collaborate with providers across the continuum of care. The Value Based Care R.N. ensures compliance with clinical guidelines, regulatory requirements, and delegated risk arrangements while driving optimal outcomes for members and contracted partners. 

Key Responsibilities: 

Care Coordination & Case Management

• Work with MSO partners and physicians to conduct comprehensive clinicalassessments for members in capitated programs to ensure appropriate level ofcare, length of stay management and repatriation of member who are out ofnetwork.
• Assist MSO Partners with coordinating services including specialist referrals, homehealth, DME, social services, and community resources.
• Monitor member progress and update care plans as needed.
• Prevent avoidable ER visits, hospitalizations, and readmissions.

Utilization & Cost Management

• Evaluate medical necessity using clinical criteria such as InterQual or MCG.
• Support utilization optimization within capitated and risk-bearing arrangements.
• Collaborate with Contracted IPA’s /MSOs to manage high-risk cases and ensureappropriate site-of-care decisions.
• Monitor utilization trends and identify opportunities for improvement.

Provider & Member Collaboration

• Serve as a liaison between Hospital and, MSO’s, physicians, , and ancillary providers.
• Ensure coordinated and effective care delivery across all stakeholders.
• Partner with MSO’s, Providers and care teams to support delegated or capitatedworkflows.

Compliance & Documentation

• Document all activities accurately in care management systems.
• Maintain compliance with Medicare, Medicaid, commercial regulations, and NCQA standards.
• Adhere to delegated risk agreements and reporting requirements.
• Participate in audits, quality reviews, and process improvement initiatives.

JOB QUALIFICATIONS

Minimum Education (Indicate minimum education or degree required.)

Preferred Education (Indicate preferred education or degree required.)

Minimum Work Experience and Qualifications (Indicate minimum years of job experience, skills or abilities required for the job.)

• Ability to communicate effectively verbally and in writing.
• Must be able to work in a union environment.
• Minimum two years’ experience as a RN in an acute care setting.

Ability to communicate effectively verbally and in writing.

Preferred Work Experience and Qualifications (Indicate preferred years of job experience, skills or abilities required for the job.)

Required Licensure, Certification, Registration or Designation (List any licensure or certification required and specify name of agency.)