Complex Care Registered Nurse

Job Responsibilities

• Own the Member Journey and Care Coordination for High-Acuity Members.
• Serve as the primary care coordinator for an assigned panel of medically complex, high-risk Medicare Advantage members — maintaining consistent engagement cadence, proactively monitoring clinical status, and ensuring all care activities across the pod are connected and moving forward.
• Build trusted relationships with members and their caregivers through regular telehealth outreach — identifying changes in condition, barriers to care, and social needs that require intervention.
• Manage Transitions of Care and Hospital Discharge Coordination.
• Own transitions of care for members discharging from hospitals, SNFs, and other inpatient settings — completing timely post-discharge outreach, medication reconciliation, and follow-up coordination to reduce avoidable readmissions and support safe, effective transitions back to the community.
• Ensure all members’ care plans are updated following transitions and that all pod team members have the clinical context needed to support the member.
• Complete Medication Reconciliations and Clinical Monitoring.
• Conduct medication reconciliations for assigned members — reviewing medication lists for accuracy, appropriateness, and adherence, identifying potential interactions or concerns, and escalating clinical findings to the APC as appropriate.
• Monitor for symptom changes, lab values, and care gap alerts — facilitating outreach and coordinating responses across the pod when abnormal findings require action.
• Escalate Clinical Concerns and Support APC Clinical Decision-Making.
• Serve as the first clinical escalation point within the pod — triaging member clinical concerns, assessing urgency, and routing to the members PCP, CAW APC or RMO for provider-level intervention when needed.
• During virtual visits and between encounters, maintain situational awareness of member health status and proactively flag emerging clinical risks before they require emergency intervention.
• Facilitate Cross-Disciplinary Care Coordination Across the Pod.
• Coordinate seamlessly with the members PCP, APCs, Health Coaches, Care Coordinators, Social Workers, and the RMO to ensure each member's care is cohesive and accountable across every role in the pod.
• Serve as the central communication point for caregivers — ensuring updates, care plan changes, and clinical concerns are shared promptly and accurately with all pod members and external care partners.
• Support HEDIS, Quality, and Care Gap Closure.
• Participate in care gap closure activities — facilitating outreach for abnormal lab values, overdue preventive services, and HEDIS measure gaps in coordination with the Care Coordinator and APC.
• Support the pod's quality performance targets by ensuring members receive timely follow-up, preventive care reminders, and education that closes documented care gaps.
• Manage Chronic Condition Care Pathways and Guideline-Directed Care Delivery.
• Proactively manage members with chronic conditions (e.g., heart failure, COPD, diabetes, CKD, and other high-risk comorbidities) through ongoing monitoring and structured care pathway oversight — ensuring care aligns with evidence-based, guideline-directed medical therapy (GDMT) and best-practice protocols.
• Identify changes in clinical status, adherence gaps, and emerging risks through regular outreach and review of clinical indicators.
• Partner with member PCPs, APCs and the pod to optimize treatment plans, escalate opportunities for medication adjustments or further evaluation, and ensure timely follow-up on labs, diagnostics, and specialty care.
• Reinforce chronic disease education with members and caregivers, including medication adherence, symptom management, lifestyle modifications, and recognition of escalation triggers.
• Document All Clinical Interactions Accurately and Timely in Athena.
• Maintain accurate, complete, and timely documentation of all member interactions, care coordination activities, medication reconciliations, escalations, and care plan updates in Athena within established timeframes.
• Ensure documentation supports HCC coding accuracy, care continuity, and compliance with CMS and organizational standards.

Requirements

• Minimum 3 years of clinical RN experience — with direct patient care in complex care, care management, transitions of care, case management, palliative care/hospice, acute care, or a related clinical setting.
• Demonstrated experience managing medically complex, high-risk patient populations — including chronic disease management, medication reconciliation, and care transition coordination.
• Prior experience in a Medicare Advantage, managed care, home-based care, or value-based care environment with working knowledge of HEDIS, HCC coding, and care gap management.
• Experience working in a telehealth or virtual care delivery model — with proficiency in virtual member engagement and remote clinical monitoring.
• Demonstrated ability to coordinate care across multiple disciplines and communicate effectively with clinical and non-clinical team members.
• Preferred: Experience with Athena EMR and TalkDesk or equivalent virtual engagement platform.
• Preferred: Formal training in motivational interviewing, health coaching, or complex care management.
• Preferred: HEDIS documentation and quality measure training.
• Preferred: Transitions of care certification or equivalent training.

Qualifications

• Required: Associate Degree in Nursing (ADN) — Bachelor of Science in Nursing (BSN) strongly preferred.
• Required: Active, unrestricted Registered Nurse (RN) license in applicable state(s).
• Required: Current BLS certification.
• Preferred: Multi-state licensure preferred.
• Preferred: Background in population health, care management programs, or complex case management for Medicare populations.
• Preferred: Certified Case Manager (CCM) or equivalent care management credential.

Skills

• Complex Care Coordination and Member Journey Management (Advanced).
• Transitions of Care and Medication Reconciliation (Advanced).
• Clinical Assessment and Escalation Judgment (Advanced).
• Telehealth and Virtual Member Engagement (Advanced).
• Athena EMR and Clinical Documentation (Advanced).
• Cross-Disciplinary Communication and Pod Collaboration (Advanced).
• HEDIS and Quality Measure Awareness (Intermediate).

Pay Range

$85,696.00 - $128,543.00