LTSS Telephonic Case Manager - Remote Patient Monitoring (RPM)

Core Responsibilities

• Complete comprehensive telephonic assessments for members receiving or applying for LTSS services
• Develop individualized care plans addressing medical, behavioral health, and social support needs
• Carefully coordinate LTSS and clinical services with providers, specialists, and community-based organizations
• Facilitate continuity of care following hospital discharge and other care transitions
• Conduct ongoing outreach to monitor progress, reassess needs, and update care plans as indicated
• Coordinate LTSS program support, including applications and documentation requirements
• Support Remote Patient Monitoring (RPM) coordination by partnering with RPM vendors, tracking engagement, and addressing barriers
• Triage and escalate high-risk findings per protocol, including RPM alerts and urgent clinical or behavioral health concerns
• Train the Feet on the Street Team on RPM device setup, unboxing, and basic troubleshooting
• Document assessments, outreach, care plans, and interventions accurately in the electronic health record (EHR)
• Identify and help close HEDIS care gaps and other quality performance measures
• Participate in quality improvement activities to strengthen care coordination outcomes
• Collaborate with interdisciplinary teams to coordinate care and align services and resources across medical, behavioral health, and social needs
• Communicate member priorities, barriers, and care plan updates to the interdisciplinary team
• Promote integrated care coordination across LTSS, medical management, and RPM services
• Support program development by contributing to policies, procedures, and workflows, and identifying opportunities for improvement

Qualifications and Education

• Active multistate Registered Nurse (RN) license required
• Certification as a Certified Case Manager (CCM) preferred
• Minimum 2+ years of experience in care management, case management, or population health
• Experience supporting Medicaid populations or complex care environments preferred
• Knowledge of Long-Term Services and Supports (LTSS) programs
• Experience using electronic health record (EHR) systems
• Ability to manage complex caseloads in a remote work environment
• Strong communication and care coordination skills