Complex Case Mangement Specialist na Proactive MD

The Complex Case Management Specialist plays a vital role in advancing Proactive MD’s Care Beyond the Walls programs by ensuring patients receive exceptional, seamless, and proactive care. This position is responsible for developing and delivering innovative case management services, optimizing care coordination, and supporting the Proactive MD Patient Promise.

In this role, you will collaborate closely with leadership teams across Patient Advocacy, Wellness Services, Clinical Operations, and Medical Affairs to design and implement solutions that enhance advanced primary care delivery. A strong focus will be placed on building multidisciplinary care models, navigating complex healthcare systems, and improving patient outcomes.

Key Responsibilities:

• Facilitate and ensure continuity of care by completing clinically weighted referrals, orders, and prior authorizations requested by Proactive MD or non-Proactive MD providers treating PMD primary care patients.

• Navigate high-value referral networks by leveraging community partners and patient insurance plans across diverse regions.

• Independently process prior authorizations and clinical orders using EMR documentation, consulting with physicians or providers when needed.

• Communicate effectively with care team members to resolve barriers to referrals, orders, or authorizations.

• Ensure provider notes and documentation are shared with specialists and imaging centers, while keeping patients informed of referral status and delays when applicable.

• Partner with Patient Advocates to coordinate outreach for specialty referrals and new or significant diagnoses, ensuring patients receive appropriate supportive care.

• Drive innovation in case management programs and contribute to the ongoing transformation of primary care delivery.

Coordination of Care

· Complete outbound clinical referrals/orders to high value providers in the community and within the patient’s insurance network.

· Complete prior authorizations for both medical services and medications.

· Notify patient that referral/order or prior authorization has been completed and ask if there are any barriers to completion of referral or accessing authorized service.

· Communicate with provider, if clinical referral is made to low value provider, when there are high value providers available to perform service.

· Communicate completion of referral process to Patient Advocate or other designated care team representative to ensure appropriate and personalized patient follow-up.

· Communicate to Patient Advocate or other designated care team representative if any barriers to completion of referral has been identified.

· Continuously search for high value providers in community using Proactive MD designated tools and other search methods.

· Notify Director, Patient Care Navigation if there are no high value providers within the community or in patient’s insurance network

· Notify Director, Patient Care Navigation if provider or care team habitually requests referrals to low value providers or facilities

Patient Engagement

· Inform and educate patient when referral or prior authorization is complete.

· Communicate anticipated timelines, as well as any barriers to completion to patient and care team.

· Explain high value providers and facilities have been selected, should patient inquire about referral direction.

· Communicate any patient concerns to Patient Advocate or other designated Health Center care team.

· Ensure Patient Advocate or other designated care team member is aware that referral has been completed.

Patient Education

· Be knowledgeable about and provide information to patients regarding community and insurance requirements around specific referral or prior authorizations.

· Provide specific point of contact for escalation of patient concerns.

Reporting & Analytics

· Utilize Proactive MD specific tools for identifying high value providers

· Update and maintain reference list, by Health Center/community of high value providers

• Required RN, with active license, BSN preferred
• 5 years of Health Plan or Provider care management experience