Complex Case Management Nurse

Oscar Health Insurance Nashville , TN 37201

Posted 3 months ago

The Complex Case Management Program is consistent with the case management industry guidelines: assessment, care planning, communication and coordination, education, empowering and advocacy. The goal of this program is to improve quality outcomes and optimize service utilization and cost.

  • The assigned Registered Nurse (RN) will operate within the company's Clinical Care Delivery department providing onsite and telephonic care management services to individuals identified as "high risk members"

  • Serve as the primary point-of-contact for a selected group of members and their families

  • Will travel between the office, member's homes and acute and subacute facilities

  • Will participate in twice weekly meetings with Medical Director to review member's progress, update the plan of care as needed

Primary Responsibilities

  • Obtains consent from the member/family for participation in Complex Case Management

  • Develops an outcome-based plan of care, based on the member's input and assessed member clinical and social needs with anticipated targeted dates for accomplishment

  • Evaluates expected outcomes and associated costs of the plan of care as well as any proposed alternative plan of care and makes necessary revisions

  • Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team

  • Conduct initial in-home or facility visit to engage and educate the member (and their family/caregivers) to the Complex Case Management program

  • Routinely conduct telephonic, in-home, and/or in-facility visits to monitor the member's adherence to their established care plans

  • Continuously coordinates, monitors, tracks and evaluates all care and services rendered to ensure that quality care is being delivered in the most appropriate setting

  • Routinely discuss members' care plans with the Medical Director to make adjustments as necessary

  • Manages transition of care ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member's health care status changes

  • Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker

  • Identifies and addresses pharmacological and DME needs of the members and facilitates consultations with the pharmacy department, as necessary

  • Responsible for the coordination of post-discharge clinic appointments, medication reconciliation, PCP and specialist visits

  • Be available (during work hours) to take incoming phone calls from assigned members (phone expense TBD)


  • Active, unrestricted RN or LVN (BSN preferred) license in Florida, Tennessee, or California

Willingness to obtain additional state licenses as needed for Oscar's growth (with Oscar's support)

  • Two years case management at a managed care plan or provider organization and

  • Excellent communication skills to effectively interact with members, families, and external healthcare providers

  • Ability to work effectively both on an individual basis and as part of a multidisciplinary team

  • Strong computer skills to maintain accurate and complete documentation in our Case Management record systems

  • Strong working knowledge of Milliman Care Guidelines

  • Highly organized and self-motivated to effectively manage multiple members

  • Adherence to all member privacy and confidentiality standards of practice (i.e. HIPAA)

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Complex Case Management Nurse

Oscar Health Insurance