Care Manager, RN

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

📋 Description

• Conduct comprehensive clinical evaluations of LTC claim files to ascertain eligibility in line with policy provisions and regulatory standards.

• Evaluate Activities of Daily Living (ADLs), cognitive impairments, diagnoses, comorbidities, and required levels of care.

• Analyze medical records, Minimum Data Set (MDS) assessments, facility documents, home health records, daily visit notes, and accompanying claim forms.

• Ascertain whether the insured fulfills the policy criteria for being Chronically Ill.

• Prepare and record Chronically Ill Certifications (CICs) and tailored Plans of Care (POCs) for initial approvals and recertifications.

• Accurately document clinical justifications to substantiate benefit determinations.

• Work collaboratively with Claims, Eligibility, and Customer Service teams to gather additional documentation as needed.

• Stay informed about LTC policy language, benefit triggers, and regulatory requirements.

⛳️ Requirements

• Must possess an active, unrestricted Registered Nurse (RN) license.

• Preferred clinical experience in long-term care, home health, geriatrics, case management, or utilization review.

• Experience in reviewing medical records and evaluating functional and cognitive impairments.

• Knowledge of LTC insurance benefit triggers, ADL requirements, and standards for chronically ill certification is preferred.

• Strong clinical judgment, critical thinking abilities, and documentation skills are essential.

• Capability to handle multiple cases simultaneously and meet turnaround expectations.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment that promotes work-life balance.