Senior Case Manager

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

📋 Description

• Evaluate claims, prior authorization requests, and ADT (admission/discharge/transfer) information to identify members who could benefit from case management.

• Perform clinical assessments and develop personalized care plans in collaboration with members.

• Collaborate directly with primary care providers, specialists, hospitals, and post-acute care providers to ensure the effective implementation of care plans and address any gaps.

• Assist members through intricate situations, including new diagnoses, hospital admissions, transitions of care, and management of chronic conditions.

• Work in conjunction with our utilization management protocols regarding medical necessity inquiries and the suitable level of care.

• Contribute to the development of our operational playbook: assist in creating protocols, escalation procedures, and the tools we utilize to execute this work effectively.

• Maintain thorough documentation and ensure compliance with relevant regulatory and accreditation requirements.

⛳️ Requirements

• Current, unrestricted RN license; a multi-state compact license is highly preferred.

• Over 5 years of clinical nursing experience, particularly in case management, utilization management, care coordination, or discharge planning.

• Proficiency in reading and interpreting claims data, prior authorization criteria (MCG/InterQual), and clinical documentation.

• Excellent communication skills — able to engage effectively with a skeptical specialist and connect with members in a compassionate manner.

• Self-motivated; capable of managing your panel independently.

• Comfortable in a dynamic environment where processes are still being developed.

🏝️ Benefits

• High ownership: You will have real responsibilities from the start—our high-trust team enables you to tackle significant challenges and shape essential aspects of the company.

• Join a vital mission: Your efforts will directly impact how individuals access care and enhance lives on a large scale.

• Growth & expansion: We are rapidly progressing, and as we expand, your role will evolve alongside us—new challenges, greater opportunities, and swift career advancement await.

• Leverage AI for meaningful impact: Rather than focusing on optimizing advertisements or reducing labor costs, you will apply AI to fundamentally transform how healthcare is delivered.

• Fast-paced, collaborative environment: We operate with speed, foundational thinking, and a team that collaborates closely, transparently, and ambitiously.