Job Description

Case Manager – Registered Nurse (RN) Remote – Must Reside in Pennsylvania

6-Month Contract | US Citizens Only | Start ASAP

The Opportunity

We are seeking an experienced Case Manager / Registered Nurse to support members with complex health needs through telephonic case management, disease management, care coordination, education, and ongoing clinical support. This role is ideal for an RN with strong clinical assessment skills who is comfortable working independently, engaging members by phone, developing individualized care plans, and helping members better manage chronic conditions and navigate the healthcare system. Candidates must hold an active Pennsylvania RN license and have prior experience in case management and managed care. Experience in Disease Management, telephonic case management, and Medicaid populations is strongly preferred. Candidates will also be required to complete the Care Manager Assessment through Glider.

What You'll Do

As a Case Manager, you will:

• Serve as a primary clinical resource for members with complex health needs, providing support ranging from health coaching through intensive case management.
• Help members develop the skills and resources needed to self-manage their conditions and successfully navigate the healthcare system.
• Conduct comprehensive telephonic clinical assessments addressing members' health, wellness, behavioral, and care-management needs.
• Use clinical assessment and motivational interviewing techniques to encourage positive health behaviors and improved self-management.
• Develop individualized, condition-specific plans of care with appropriate short- and long-term goals.
• Establish regular telephonic follow-up schedules to monitor progress, identify changing needs, and adjust care plans as appropriate.
• Coordinate with treating physicians and other healthcare providers when members require more complex case-management intervention.
• Provide education, consultation, and clinical support to other care-management teams when needed.
• Identify community, online, telephonic, and healthcare resources that can help members achieve their personal health goals.
• Assist members in accessing appropriate healthcare and community-based services.
• Incorporate preventive health, lifestyle improvement, and wellness opportunities into member interactions.
• Document all case-management activities accurately and in accordance with organizational procedures, regulatory requirements, and accreditation standards.
• Assist with coordination of specialized healthcare services when appropriate, including designated centers of excellence.
• Collaborate with Benefits Analysts and other internal partners regarding benefits, appeals and denials, provider inquiries, claims processing, and related member needs.
• Perform additional case-management and care-coordination responsibilities as assigned.

What We're Looking For

Required Qualifications

• Active and unrestricted Registered Nurse license in Pennsylvania
• 5+ years of relevant healthcare experience
• Prior case management experience
• Prior experience working within managed care
• Strong clinical assessment skills
• Knowledge or experience in Disease Management
• Experience developing and managing care plans
• Experience conducting telephonic member outreach
• Knowledge of community-based healthcare resources
• Understanding of preventive health services
• Excellent verbal and written communication skills
• Ability to work independently in a remote environment
• Strong work ethic, organization, and follow-through

Highly Preferred Experience

• Disease Management experience
• Telephonic Case Management experience
• Experience working with Medicaid populations
• Certified Case Manager (CCM) credential
• High-volume or 1-800-line member support experience
• Care coordination and member education experience

What the Hiring Manager Is Prioritizing

The hiring manager is particularly interested in Registered Nurses with strong Disease Management experience and excellent clinical assessment skills. The strongest candidates will have experience providing:

• Disease Management support
• Telephonic clinical assessments
• Care coordination
• Member education
• Chronic-condition management
• Case management
• Medicaid member support