Care Management Specialist

About the role

The Care Management Specialist provides nursing expertise to assess, plan, and coordinate comprehensive care for policyholders with chronic medical conditions. This role ensures optimal health outcomes by developing individualized care plans, overcoming barriers, and facilitating timely access to services.

Key responsibilities

• Evaluate admission criteria for Complex Care Management Programs and conduct health risk assessments.
• Develop and document individualized care plans with specific goals, using clinical guidelines.
• Identify and address barriers to care, establishing short‑ and long‑term case management strategies.
• Guide patients and families through acceptance and adaptation to chronic conditions, providing follow‑up support.
• Maintain accurate electronic documentation of progress, actions, and care plans.
• Communicate effectively with physicians, service providers, and patients to coordinate treatment and promote self‑care.
• Participate in interdisciplinary case discussions and adjust care plans as needed.
• Coordinate referrals to meet clinical and social needs across departments.
• Execute Organizational Determinations and Transitional Care processes in compliance with regulatory timelines.
• Contribute to initiatives aimed at achieving quality metrics such as HEDIS and Star ratings.

Required profile

• Bachelor’s degree in Nursing Sciences.
• Minimum two years of direct care experience with patients who have chronic health conditions.
• Valid nursing license and registration with the Association of Nursing Professionals of Puerto Rico.
• Intermediate proficiency in both Spanish and English (written and verbal).

Required skills

• Proficiency with MS Office applications.
• Experience using electronic documentation applications for care planning.