Care Manager

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

📋 Description

• Identify and link high-risk members to suitable resources and programs to ensure optimal quality and financial results.

• Oversee and prioritize self-referrals to care management initiatives.

• Detect high-risk members using HRA, reporting, and admissions information.

• Review patient charts and member records for delegated case management programs in line with NCQA standards.

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

• Conduct utilization management reviews based on established criteria, clinical guidelines, and policies.

• Identify obstacles impacting members’ quality of life.

• Analyze Health Risk Assessment and member outcome data to facilitate program development and performance enhancement.

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

• Examine medical records and documentation to ensure the provision of quality care.

• Engage in care management, case management, and quality committees.

• Review and amend activities, resources, policies, and procedures to meet member needs and align with delegated processes.

• Assist in quarterly reporting and the submission of necessary documents and policies to comply with accreditation standards.

⛳️ 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).

• At least three years of clinical experience in the healthcare sector.

• Familiarity with InterQual and/or Milliman Care Guidelines.

• Understanding of federal and state laws, NCQA standards, and industry regulations related to disease management, utilization management, care management, and discharge planning.

• Exceptional written and verbal communication skills.

• Strong problem-solving abilities to enhance 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.

• Enrollment in a BSN program, with completion of the BSN 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

• Remote work location.

• Full-time schedule with 40 scheduled hours per week.

• Exempt status.