CASE MANAGEMENT COORDINATOR JOB DESCRIPTION

Gaps in discharge planning show up fast - readmission rates climb, payers push back, and members fall through without support. Short. The Case Management Coordinator fills that gap by owning the coordination layer between clinical teams, health plan benefits, and community resources in managed care and acute hospital environments. Working within utilization management and quality management frameworks, this role ensures members move through care transitions with the right services in place. NCQA compliance and HCBS waiver navigation shape much of the daily work.

As the Case Management Coordinator, you drive member outcomes by managing care plans, coordinating provider activity, and ensuring compliance with regulatory and accreditation standards across the health services continuum. You operate within a multidisciplinary care team, supporting case managers, Medical Directors, and community partners to close gaps between clinical decisions and real-world member needs.

Career Impact: Coordinating care across managed care organizations and acute settings builds rare cross-sector expertise that is valued at every level of healthcare operations.

Business Impact: Members with complex needs - including intellectual developmental disabilities and serious emotional disturbances - receive coordinated support that directly reduces preventable readmissions and improves health plan performance.

Growth Opportunity: Experience spanning utilization management, discharge planning, and HCBS waiver programs positions you for senior case management or care management leadership roles.

• Evaluate referred members' eligibility and benefit plans to recommend appropriate case resolution approaches.
• Coordinate care plan activities from admission through post-discharge, monitoring progress against established goals.
• Triage incoming cases for completeness and priority, routing each to the appropriate care team member.
• Identify high-risk factors for readmission and escalate to clinical case management or crisis intervention as warranted.
• Partner with providers to monitor discharge status, confirm member activity, and arrange required community services.
• Audit case documentation and care plan data to maintain compliance with NCQA standards and accreditation requirements.
• Conduct member outreach via phone to reinforce discharge instructions and support independent health decision-making.
• Review readmission metrics and present findings at multidisciplinary case conferences to support continuous quality improvement.

• Bachelor's degree in behavioral health, human services, or a related field, or equivalent work experience.
• 2 or more years of case management experience, with demonstrated involvement in discharge planning or care coordination.
• Experience working within managed care organizations or health plan environments.
• Knowledge of utilization management, healthcare reimbursement, and community-based service systems.
• Familiarity with HCBS waiver programs and the populations they serve.
• Strong interpersonal and motivational interviewing skills to engage members across complex health situations.
• Ability to manage multiple cases simultaneously while maintaining documentation accuracy and regulatory compliance.

• Certification in Case Management (CCM or equivalent) from a recognized credentialing body.
• Clinical licensure or advanced degree in social work, counseling, marriage and family therapy, or nursing.
• Experience supporting patients with intellectual developmental disabilities or serious emotional disturbances.
• Bilingual proficiency in English and Spanish to serve diverse member populations.

• Readmission rate within 30 days, reflecting effectiveness of discharge coordination and post-acute follow-up.
• Care plan completion rate, measuring timely activation of assigned member services.
• NCQA audit pass rate, indicating documentation accuracy and compliance across managed cases.
• Member engagement rate, tracking outreach contact success and program enrollment among high-risk populations.
• Case triage turnaround time, reflecting how quickly incoming referrals are assessed and routed.
• Typical tools: Electronic health records (commonly Cerner or equivalent); care management platforms (commonly MS Office Suite including Outlook and Excel).

• Base Salary Range: $45,000 to $62,000 per year
• Bonus: Annual performance bonus, typically 3 to 5%
• Equity: Not typically offered at this level
• Health Benefits: Medical, dental, and vision coverage
• PTO: 15 to 20 days annually plus paid holidays
• Common Perks: Mileage reimbursement for field travel, continuing education support, licensure fee assistance

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background checks, including criminal history and applicable drug screening, are a condition of employment for all positions. All qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the hiring process upon request. Candidates must be authorized to work in the United States.

The Case Management Coordinator owns the end-to-end care coordination process within Aetna's Health Services division, utilizing critical thinking and motivational interviewing to facilitate appropriate healthcare outcomes for members across utilization management, quality management, and network management programs. Reporting to health services leadership and collaborating with case managers, Medical Directors, and community programs, the coordinator ensures member benefit plans are evaluated and care plan activities are implemented in compliance with regulatory and accreditation guidelines.

Key Responsibilities

• Utilize critical thinking and judgment to collaborate and inform the case management process to facilitate appropriate healthcare outcomes for members.
• Conduct comprehensive evaluation of referred members' needs and eligibility through care management tools and data review.
• Recommend approaches to case resolution by evaluating member benefit plans and available internal and external programs.
• Identify high-risk factors and service needs that may impact member outcomes and care planning components.
• Coordinate and implement assigned care plan activities and monitor care plan progress.
• Consult with case managers, supervisors, Medical Directors, and other health programs using a holistic approach to overcome barriers.
• Identify and escalate quality of care issues through established channels.
• Utilize negotiation and motivational interviewing skills to secure appropriate services and promote member engagement.
• Provide coaching, information, and support to empower members to make informed healthcare and lifestyle decisions.
• Utilize case management and quality management processes in compliance with regulatory, accreditation, and company guidelines.

Education & Experience

• Bachelor's degree or non-licensed master's degree in behavioral health or human services (psychology, social work, marriage and family therapy, or counseling) required.
• Minimum 1 year of experience in behavioral health, social services, or human services field.
• 1 year of experience in Home and Community Based Services (HCBS) waiver.
• Experience working with patients with intellectual developmental disabilities or children with serious emotional disturbances highly preferred.
• Case management and discharge planning experience preferred.
• Managed Care experience preferred.
• Minimum 1 year of experience with MS Office Suite.
• Valid Driver's License required.
• Willing and able to travel 50–75% of the time using own vehicle within the Central and Western KS region.

Embedded within a managed care team, the Case Management Coordinator delivers administrative and operational support across care plan management, provider coordination, and NCQA compliance auditing to ensure members receive timely and appropriate services. Working closely with case managers and care team members, the coordinator serves as the primary liaison among providers, community resources, and internal staff to facilitate member engagement and continuity of care.

Core Functions

• Screen care management cases to ensure information is complete and accurate, and help prioritize and triage cases to the appropriate person.
• Interact with providers to monitor member discharge status, confirm member activity, set up appointments, and support other provider-related activities.
• Identify and utilize health plan benefits and local community resources to help meet member needs, and share knowledge across the team.
• Assist in report production, data collection, and data entry for care plan management, and perform process auditing for NCQA compliance.
• Research member information including clinical history, utilization patterns, and benefits, and present findings to the care team.
• Arrange required services for members and perform other case management support activities including telephonic contact as needed.
• Act as the liaison among all care team members and promote collaborative teamwork.
• Perform other duties as assigned or requested.

Required Qualifications

• High School Diploma or GED required.
• 3–5 years of experience performing administrative support functions in a healthcare office or field setting.
• Experience in a healthcare-related customer service or marketing environment preferred.
• Basic knowledge of care management processes.
• Knowledge of administrative and clerical procedures including word processing, file management, and form design.
• Proficient computer skills including MS Office products.
• Ability to navigate multiple systems simultaneously and take direction effectively.
• Ability to communicate and work cooperatively with all levels of staff and management.
• Ability to handle multiple tasks simultaneously and respond to customers promptly.

Reporting to hospital care management leadership, the Case Management Coordinator shapes patient outcomes by identifying high-risk readmission cases, coordinating care from admission through 30 days post-discharge, and reinforcing discharge plans through telephonic follow-up with patients and families. Partnering with nursing, pharmacy, physicians, and community services, this coordinator drives adherence to readmission reduction metrics and supports multidisciplinary quality improvement efforts across the acute hospital setting.

Primary Duties

• Identify patients with high-risk conditions for readmission using Cerner software and facilitate decision-making to ensure resolution of care issues.
• Educate and coach patients and families in disease self-management during hospital stay and post-discharge.
• Reinforce medication education provided by nursing, pharmacy, and physician for the identified patient population.
• Coordinate care of at-risk patients from admission through 30 days post-discharge, promoting effective utilization of resources and community services.
• Provide telephone reinforcement of discharge plans and document follow-up in the electronic patient record via Cerner.
• Review and analyze adherence with readmission metrics and follow up on monthly reports as needed.
• Participate in readmission meetings and webinars, and assist in educating hospital staff on readmission practices.

Qualifications & Experience

• BSN or Master's degree preferred.
• Florida RN license, Certification in Case Management, and CPR certification required.
• Minimum 3–5 years of clinical experience in an acute hospital setting.
• Minimum 2–4 years of case management experience in a healthcare setting preferred.
• Knowledge of health care reimbursement, utilization management, discharge planning, community resources, and disease management in acute and post-acute settings.
• Computer proficiency including MS Outlook, Excel, and electronic medical record systems.
• Critical thinking, organizational, interpersonal, negotiation, and time management skills required.
• Bilingual in English and Spanish a plus.

Sitting at the intersection of clinical operations and compliance, the Case Management Coordinator leads medical necessity determinations, quality oversight, and policy implementation to optimize member outcomes and total cost of care within a managed care organization. Collaborating with colleagues at all levels and serving members in the South Chicago region, the coordinator ensures continuous compliance, patient advocacy, and effective decision-making aligned with program directives.

Duties

• Determine medical necessity and appropriateness for members.
• Facilitate optimal outcomes through coordinated care activities.
• Identify and follow through on continuous quality and compliance opportunities, including identification of aberrances and initiation of corrective action.
• Educate and empower customers to ensure compliance, satisfaction, and patient advocacy.
• Optimize total costs across care management activities.
• Implement and evaluate policy based on usage and program directives.
• Educate and empower colleagues at all levels to enable decision-making at the most appropriate level.

Skills & Qualifications

• 2+ years of experience in behavioral health, social services, human services, or a related field required.
• 2+ years of case management experience required.
• MCO experience preferred.
• Waiver experience preferred.
• 1+ year of computer proficiency in Microsoft Word, Excel, and Outlook required.
• Must reside in and be willing to travel within South Chicago, IL.