Case Manager, Registered Nurse

This is a fully remote position, open to applicants in Alabama, +45 more states.

📋 Description

• Engage actively as a telephonic case manager, collaborating with patients and their care teams for fully and/or self-insured clients.

• Apply and interpret relevant criteria, clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards.

• Evaluate benefits and member needs to guarantee the effective administration of benefits.

• Utilize clinical judgment to mitigate risk factors and barriers, addressing complex health and social determinants impacting care planning.

• Conduct assessments by gathering information from various sources, including co-morbidities and multiple diagnoses that influence functionality.

• Collaborate with supervisors and other stakeholders to navigate barriers and accomplish goals and objectives.

• Present cases at case conferences for multidisciplinary evaluation and comprehensive claim management.

• Consult with clinical peers, supervisors, Medical Directors, and other programs, adopting a holistic approach.

• Implement case management processes in alignment with regulatory and company policies and procedures.

• Employ motivational interviewing techniques to enhance member engagement and ascertain health status and needs.

• Recognize and escalate member needs appropriately, following established guidelines and protocols.

• Proactively reach out to members to collaborate on and steer their care journey.

• Conduct medical necessity reviews.

⛳️ Requirements

• A minimum of 5 years’ experience as a Registered Nurse, including at least 1 year in a hospital environment.

• Active multistate RN license through the Nurse Licensure Compact (NLC) for nurses in compact states, or individual state-specific RN licenses for nurses in non-compact states.

• Over 1 year of experience documenting electronically using a keyboard.

• More than 1 year of current or prior experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse, or Maternity/Obstetrics.

• Nursing diploma or Associate's Degree in Nursing is required.

• Preferably over 1 year of experience in Case Management, discharge planning, nurse navigation, or nurse care coordination.

• Preferably over 1 year of experience in transitioning patients to lower levels of care.

• Preferably over 1 year of experience in Utilization Review.

• CCM and/or other URAC recognized accreditation is preferred.

• Preferably over 1 year of experience with MCG, NCCN, and/or Lexicomp.

• Bilingual in Spanish is preferred.

• A Bachelor’s degree is preferred.

🏝️ Benefits

• Medical coverage

• Dental coverage

• Vision coverage

• Paid time off

• Retirement savings options

• Wellness programs

• Additional resources promoting physical, emotional, and financial well-being

• Virtual training