[Hiring] Case Manager Nurse-RN @Personify Health

Role Description

As a Case Manager RN, you will provide telephonic case management between providers, patients, and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. May be required to work evening and/or weekend shifts.

• Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
• Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs.
• Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources, and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
• Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions.
• Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care.
• Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
• Be able to meet productivity, quality, and turnaround time requirements on a daily, weekly, and monthly basis.
• Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports.
• Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance, and information.
• Evaluate and make referrals for wellness programs.
• Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site-specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases ensuring confidentiality according to Company policy and HIPAA.
• Perform Utilization Review for assigned members.
• Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issues.

Qualifications

• Graduation from an accredited Registered Nursing (RN) program.
• Possession of a current California RN license; a multi-state license will also be required.
• Minimum of five (5) years medical/surgical or acute care experience, including two years’ experience in case management, or an equivalent combination of education and experience.
• Prior case management experience, emergency room, critical care background, or other relevant clinical care experience pertinent to case management.

Requirements

• Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
• Ability to critically evaluate claims data and determine treatment plan, discharge planning experience.
• Ability to work independently making decisions and problem solving.
• Knowledge of community resources and alternate funding programs.
• Computer proficiency or working knowledge of Microsoft Office Suite.
• Excellent interpersonal, communication, and negotiation skills.
• Strong customer orientation.
• Good time management skills and highly organized.

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.