Case Manager Registered Nurse (LTSS) - Field MI (Wayne and Macomb County)

About the role

The LTSS RN Case Manager is responsible for comprehensive assessment, care planning, coordination, implementation, and monitoring of Long-Term Services and Supports (LTSS) for dual-eligible Medicare and Medicaid members. This role ensures members receive appropriate waiver and community-based services to promote safety, independence, and improved health outcomes while maintaining regulatory compliance.

Responsibilities

• Conduct comprehensive in-home LTSS assessments to determine eligibility for waiver and community-based services.
• Complete and submit required waiver documentation in accordance with state Medicaid and health plan guidelines.
• Develop and implement individualized, person-centered plans of care addressing medical, behavioral, functional, and social determinant needs.
• Apply clinical judgment to identify risk factors, prevent avoidable hospitalizations, and reduce barriers to care.
• Cookordination services across interdisciplinary teams including providers, home health agencies, behavioral health, and community organizations.
• Review claims data, clinical records, and assessment tools to evaluate member needs and benefit utilization.
• Monitor member progress and reassess needs based on changes in condition or level of care.
• Present cases at interdisciplinary team (ICT) meetings and collaborate with supervisors and stakeholders to ensure goal attainment.
• Ensure compliance with Medicaid waiver requirements, CMS regulations, state LTSS guidelines, and company policies.
• Document all case management activities in accordance with regulatory and accreditation standards.
• Educate members and caregivers regarding benefits, services, and available community resources.

Requirements

• Active, unrestricted Registered Nurse (RN) license in the state of Michigan.
• Associate or Bachelor of Science in Nursing (BSN preferred).
• Minimum of 2 years of clinical nursing experience.
• Minimum of 1 year of experience in case management, care coordination, home health, hospice, or long-term care.
• Experience working with Medicare, Medicaid, or dual-eligible populations.
• Knowledge of Long-Term Services and Supports (LTSS), home and community-based services (HCBS), and waiver programs.
• Experience conducting in-home assessments and developing person-centered service plans.
• Strong understanding of social determinants of health and community resource navigation.
• Ability to travel 25-50% within assigned counties, including completion of in-home field visits; reliable transportation is required.
• Proficient in electronic medical records and care management platforms.

Qualifications

• Preferred: Certified Case Manager (CCM) or willingness to obtain within 2 years.
• Experience in managed care or health plan environment.
• Knowledge of Michigan Medicaid waiver programs and state LTSS regulations.
• Experience presenting cases in interdisciplinary team (ICT) settings.
• Bilingual skills preferred.

Skills

• Strong clinical assessment and critical thinking skills.
• Excellent communication and member engagement skills.
• Ability to manage a high-risk, complex caseload.
• Regulatory and compliance knowledge.
• Independent decision-making in a remote environment.
• Effective computer skills including navigating multiple systems and keyboarding.
• Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint.

Benefits

• Medical, dental, and vision coverage.
• Paid time off.
• Retail savings options.
• Wellness programs.
• Other resources.