Registered Nurse Care Manager

Job Description

Blue Zones Health is a lifestyle-first well-being organization that partners with primary care providers and health plans to deliver whole-person care that improves outcomes, reduces unnecessary utilization, and supports patients beyond the four walls of the clinic. Our model integrates lifestyle medicine, health coaching, and social support to address the real drivers of health—especially social, behavioral, and environmental needs.

Position Summary

As the RN Care Manager, you will lead clinical care management for all members—focusing on chronic disease, SNP model-of-care patients, and both inpatient and emergency department transitions. You’ll develop individualized care plans, ensure seamless discharge planning, and act as a clinical liaison across settings to optimize outcomes, reduce readmissions, and improve member satisfaction.

This role offers a unique opportunity to collaborate with Well-Being Services and Health Coaches to integrate lifestyle medicine into care management. Together, you’ll support members through care coordination, self-management strategies, and holistic approaches that improve health and well-being.

The compensation range for this role is $90,000 - $100,000.

Key Responsibilities:

Chronic Disease & Population Health Management

• Work with population health team to identify high- and rising-risk members through data analysis and risk stratification tools.
• Perform comprehensive clinical assessments (telehealth, or telephonic) to evaluate medical, functional, psychosocial, and environmental factors.
• Develop, implement, and monitor individualized care plans in partnership with members, caregivers, providers, and the interdisciplinary care team.
• Educate members and caregivers on disease self-management, medication adherence, lifestyle modifications, and preventive care.

SNP Model of Care Compliance

• Assist with implementing SNP-specific Model of Care (MOC) requirements including health risk assessments, individualized care plans, and care coordination protocols.
• Participate in interdisciplinary care team meetings and MOC quality improvement activities.

Transitions of Care & Discharge Planning

• Coordinate transitions from hospital, SNF, and ER settings and ensure timely follow-up, meeting DME/Home Health needs, medication reconciliation, and appropriate referrals.
• Conduct post-discharge outreach to reduce readmissions and ensure continuity of care.

Care Coordination & Collaboration

• Serve as clinical liaison between providers, specialists, community agencies, and caregivers.
• Facilitate warm handoffs, interdisciplinary huddles, and case conferences for complex cases.

Documentation, Performance Tracking & Quality Improvement

• Accurately document care management encounters and care plan updates in the EMR and care management systems.
• Track clinical outcomes, utilization metrics, readmission rates, and SNP performance measures (e.g., HEDIS).
• Collaborate in quality improvement initiatives aimed at program enhancements.

Qualifications and Experience:

Education & Licensure

• Valid Registered Nurse (RN) license in California
• BSN preferred
• Minimum 3+ years in care management, chronic disease management, or utilization management (including inpatient or transitions roles).
• Hands-on experience with SNP Model of Care compliance and care team coordination.

Certifications

• Certified Case Manager (CCM) or relevant certification preferred.

Skills & Competencies

• Proficiency in clinical assessment, care planning, chronic disease coaching, discharge planning, and care coordination.
• Strong clinical judgment, problem-solving, organization, and independent work capabilities.
• Excellent verbal and written communication skills, with an ability to influence and collaborate across teams.
• Technical fluency with EMRs, care management platforms, and telehealth tools.

Working Conditions

• Hybrid work model; may require in-person presence at care team meetings or site visits for transitions of care.
• Telephonic, telehealth outreach.

For more information about Blue Zones Health, check us out at www.bluezoneshealth.com.

Blue Zones Health does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age, disability, veteran status, or any other protected status under applicable law.