[Hiring] Case Management Nurse RN @Personify Health

Role Description

Ready to turn complex medical journeys into clear plans and better outcomes?

When a member faces a serious diagnosis or a difficult recovery, they need someone in their corner who knows the system and can make it work for them. That’s you. As a Case Manager, you’ll assess the whole person, build care plans that fit their life, and connect them with the providers and programs that move them forward. Your clinical judgment improves outcomes while ensuring care is used appropriately and costs stay in check. You’ll also guide LVNs and LPNs on complex cases and set the standard for documentation and compliance. When you do this well, members get better care and the organization earns the trust that keeps our programs strong.

What You’ll Actually Do:

• Manage cases by phone:
• Lead short- and long-term cases in line with company guidelines, policies, and industry criteria (NCQA, CMSA, URAC), keeping members moving toward their goals.
• Assess the whole person:
• Conduct comprehensive biopsychosocial assessments covering physical, emotional, psychosocial, spiritual, environmental, and financial factors so every care decision starts with the full picture.
• Find the story in the claims:
• Use claims-processing tools to review paid claims, identify health trends, and determine eligibility for case management programs.
• Build and refine care plans:
• Develop and update individualized treatment plans for standard and catastrophic cases with measurable short- and long-term goals.
• Prove the impact:
• Evaluate intervention effectiveness and document measurable outcomes that show clinical impact and cost savings.
• Keep everyone connected:
• Maintain continuous communication with members, caregivers, providers, employers, and the multidisciplinary team throughout the course of care.
• Advocate for quality and value:
• Champion quality patient care while supporting appropriate utilization and reducing overall healthcare costs, and refer members to chronic disease, wellness, behavioral health, and vendor-specific programs as needed.
• Drive cost management:
• Implement cost management strategies and document results in case management reviews and cost-avoidance reporting.
• Support utilization review:
• Assist with Utilization Review for assigned members to keep care appropriate and well coordinated.
• Mentor and guide:
• Coach LVNs and LPNs and support complex case guidance within licensure scope.
• Set the compliance standard:
• Serve as a subject-matter expert in NCQA, URAC, and CMSA standards and documentation best practices, maintain compliance with CMS and other regulatory audit standards, and keep accurate, confidential records per company policy and HIPAA.
• Deliver every day:
• Meet daily, weekly, and monthly productivity, quality, and turnaround standards, and complete required annual education and competencies.

This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs.

Qualifications

• Graduate of an accredited nursing program
• Current RN license required based on business need
• 3 years of medical/surgical or acute care experience
• Working knowledge of NCQA, URAC, CMSA, and CMS standards and HIPAA requirements
• Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
• Proficiency in Microsoft Word, Excel, and Outlook
• Basic computer literacy, proficient typing, and the ability to work across multiple screens
• Proficiency in Teams (on and off camera), SharePoint, shared drives, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Smartsheet, and a phone system with headset; additional programs may apply based on job duties
• Full system proficiency expected after training and a 1.5-month ramp (3 months total)

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

This position offers a base salary range of $35.00-$37.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected] . View all legitimate openings at personifyhealth.com/careers .