Case Manager – Nurse, RN

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

📋 Description

• Facilitate telephonic case management between patients, providers, and caregivers to promote high-quality, cost-effective healthcare for participants of health insurance plans.

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

• Utilize claims processing tools to analyze and investigate paid claim data, forming a clinical overview of a member’s health and identifying suitable program participation.

• Collaborate with the patient, caregivers or family, community resources, and multidisciplinary healthcare providers to create treatment plans for both standard and catastrophic cases, incorporating achievable short- and long-term objectives.

• Assess interventions and review the effectiveness of the treatment plan promptly; document measurable outcomes that reflect the success of interventions.

• Establish and maintain communication with the patient/family, providers, employers, and multidisciplinary teams as necessary throughout the care continuum.

• Advocate for patients by ensuring the provision of quality care and assisting in minimizing overall costs; offer emotional support and guidance to patients and their families.

• Develop and execute cost management strategies aimed at achieving quality outcomes, documenting this information in monthly case management reviews and cost avoidance reports.

• Build and sustain collaborative relationships with healthcare providers, clients/groups, and patients to deliver emotional support, guidance, and information.

• Assess and make referrals to wellness programs.

• Keep thorough and precise documentation of case-managed patients in Eldorado and UM Web; ensure confidentiality by maintaining site-specific files and preparing reports and updates at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases in compliance with Company policy and HIPAA.

• Conduct Utilization Review for assigned members.

• Mentor LVNs and provide guidance on complex cases regarding clinical issues.

⛳️ Requirements

• Graduation from an accredited Registered Nursing (RN) program.

• Current California RN license; a multi-state license is also required.

• At least five (5) years of experience in medical/surgical or acute care settings, including two years in case management, or a combination of education and experience that is equivalent.

• Previous case management experience, along with background in emergency room, critical care, or other relevant clinical care experiences related to case management.

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

• Ability to critically assess claims data and formulate treatment plans, along with discharge planning experience.

• Capability to work independently, making decisions and solving problems effectively.

• Awareness of community resources and alternative funding programs.

• Proficiency in computers or a working knowledge of Microsoft Office Suite.

• Strong interpersonal, communication, and negotiation skills.

• Excellent customer service orientation.

• Good time management abilities and a high level of organization.

🏝️ Benefits

• Competitive base salary and benefits starting on day one.

• Comprehensive medical and dental coverage through our own health solutions (we utilize our own services).

• Paid Time Off—ensuring rest and recharge time is imperative.

• Support for mental health, retirement planning, and financial protection.

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

• A mission-driven culture where diverse perspectives contribute to meaningful impacts on people's health.