Case Manager, Nurse, RN

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

📋 Description

• Directly engage with patients to conduct comprehensive assessments that encompass physical, psychosocial, emotional, spiritual, environmental, and financial needs.

• Utilize claims processing tools to analyze paid claim data and identify members who require case management or specific programs.

• Collaborate with patients, caregivers, community resources, and multidisciplinary providers to create treatment plans for both standard and catastrophic cases.

• Establish clear short-term and long-term objectives.

• Oversee interventions and assess the effectiveness of treatment plans.

• Document measurable outcomes.

• Maintain continuous communication with patients, families, providers, employers, and the wider care team throughout the care continuum.

• Help facilitate access to quality care while providing emotional support and guidance.

• Negotiate and implement strategies for cost management.

• Reflect the impact of cost management in monthly case management reviews and cost avoidance reports.

• Conduct utilization reviews for assigned members.

• Assess patient needs and refer them to wellness programs as necessary.

• Ensure complete and confidential documentation in Eldorado and UM Web.

• Prepare reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases in line with company policy and HIPAA regulations.

• Act as a clinical resource for LVNs, guiding complex cases and clinical decision-making.

⛳️ Requirements

• Must be a graduate of an accredited Registered Nursing (RN) program.

• A current California RN license is required.

• A multi-state license is also necessary.

• Minimum of 5 years of medical/surgical or acute care experience, including at least 2 years in case management, or a suitable combination of education and experience.

• Previous experience in case management, emergency room, critical care, or other relevant clinical areas related to case management is essential.

• Familiarity with medical claims processing and knowledge of ICD-10, CPT, and HCPCS coding is required.

• Ability to critically assess claims data to guide treatment and discharge planning.

• Awareness of community resources and alternative funding programs.

• Proficient in Microsoft Office Suite.

• Working knowledge of case management platforms such as Eldorado and UM Web.

🏝️ Benefits

• Competitive base salary and benefits starting on the first day.

• Comprehensive medical and dental coverage through our proprietary health solutions.

• Paid Time Off.

• Mental health support services.

• Retirement planning assistance.

• Financial protection options.

• Opportunities for professional development with clear career progression and learning budgets.

• A mission-driven culture that values diverse perspectives and fosters real impact.

• Wellness program offerings.

• Additional employee perks.

• Full benefits package available from day one.