Care Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Identify and engage high-risk members with suitable resources and programs to ensure optimal quality and financial outcomes.

• Manage and prioritize member self-referrals to care management programs.

• Recognize high-risk members utilizing HRA, reporting, and admissions data.

• Conduct audits of patient charts and member records for delegated case management programs according to NCQA standards.

• Connect members with in-network healthcare providers, medical benefits, and community resources.

• Participate in the development, implementation, oversight, and delegation of care management programs.

• Execute utilization management reviews in alignment with established criteria, clinical guidelines, and policies.

• Identify and address barriers that impact members' quality of life.

• Assess HRA and member outcomes data to enhance programs, services, and performance improvement.

• Investigate potential quality-of-care concerns that may affect member health or safety.

• Review medical records and documentation to ensure the delivery of quality care.

• Engage in case management and quality committees.

• Review and update resources, policies, and procedures to meet member needs and delegated processes.

• Assist with quarterly reporting and accreditation documentation.

⛳️ Requirements

• A current Registered Nurse license issued by the state where services will be provided, or a current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

• A minimum of three years of clinical experience in healthcare.

• Familiarity with InterQual and/or Milliman Care Guidelines.

• Knowledge of federal and state laws, NCQA, and industry regulations pertaining to disease management, utilization management, care management, and discharge planning.

• Exceptional written and verbal communication skills.

• Strong problem-solving skills aimed at enhancing efficiencies and customer satisfaction.

• Keen attention to detail.

• Proficient in Microsoft Office applications.

• A Bachelor's Degree in Nursing or an Associate of Science in Nursing Degree (ASN) is preferred.

• Currently enrolled in a BSN program with completion within three years of hire is preferred.

• Experience managing Medicare and/or Medicaid populations is preferred.

• A minimum of two years of experience in Care Management is preferred.

🏝️ Benefits

• Comprehensive health insurance.

• Retirement savings plan with employer matching.

• Paid time off and holidays.

• Opportunities for professional development and continuing education.

• Supportive work environment focused on team collaboration.