Case Manager – Nurse RN

📋 Description

• Facilitate telephonic case management among providers, patients, and caregivers to ensure cost-effective and high-quality healthcare for participants in health insurance plans.

• Reach out to patients and conduct a comprehensive assessment, addressing physical, psychosocial, emotional, spiritual, environmental, and financial needs.

• Utilize claims processing tools to analyze and investigate paid claim data to create a clinical profile of a member’s health and identify appropriate program participation.

• Formulate treatment plans for both standard and catastrophic cases.

• Oversee interventions and assess the effectiveness of treatment plans promptly.

• Document measurable outcomes that reflect the effectiveness of interventions.

• Establish and maintain communication with the patient/family, provider, employer, and multidisciplinary team as necessary throughout the care continuum.

• Act as an advocate for the patient by facilitating the provision of quality care.

• Negotiate and implement cost management strategies aimed at achieving quality outcomes.

• Keep thorough and detailed records of patients under case management.

⛳️ Requirements

• Completion of an accredited Registered Nursing (RN) program.

• Current California RN license required; a multi-state license will also be necessary.

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

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

• Familiarity with medical claims as well as ICD-10, CPT, and HCPCS coding.

• Capability to critically assess claims data and determine appropriate treatment plans.

• Experience in discharge planning.

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

• Knowledge of community resources and alternative funding programs.

• Proficiency in computer skills, particularly with Microsoft Office Suite.

• Exceptional interpersonal, communication, and negotiation abilities.

• Strong customer service orientation.

• Excellent time management skills and high level of organization.

🏝️ Benefits

• Competitive base salary and benefits starting from day one.

• Comprehensive medical and dental coverage through our proprietary health solutions (yes, we utilize what we create).

• Paid Time Off—time to rest and recharge is essential and non-negotiable.

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

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

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