Case Management Nurse

Innovative Care Management, Inc.•Washington, NV

9d•Remote

About The Position

The Case Manager Nurse plays a critical role in supporting members with complex or chronic conditions by providing proactive, telephonic case management grounded in a whole-person approach. This role focuses on reducing avoidable utilization, improving care coordination, and helping members navigate the healthcare system with confidence and clarity. As a trusted clinical resource, the Case Manager Nurse partners closely with members, providers, and health plans to assess needs, develop individualized care plans, and advocate for appropriate, cost-effective services. In addition to core case management responsibilities, this role also supports utilization review activities when needed, contributing to timely medical necessity determinations and continuity of care. This position is ideal for an experienced RN who brings strong clinical judgment, excellent communication skills, and a passion for improving outcomes for high-need populations in a collaborative, remote care management environment. This is a fully remote role. Candidates must reside in Oregon, Washington, Nevada, or Arizona. Schedule: Monday–Friday | 8:00 AM–5:00 PM Pacific Time

Requirements

Active, unrestricted Registered Nurse (RN) license in good standing
Associate’s or Bachelor’s degree in Nursing
5+ years of clinical nursing experience
Strong knowledge of chronic disease management, utilization management, and social determinants of health
Experience managing complex, high-utilization patient populations
Excellent written and verbal communication skills with empathy, professionalism, and emotional intelligence
Strong organizational skills with the ability to manage multiple priorities independently
Sound clinical judgment and confidence navigating complex or sensitive situations
Comfort working independently in a remote environment with strong accountability and follow-through
Ability to manage confidential information in compliance with HIPAA

Nice To Haves

Experience in case management, care coordination, or discharge planning
Experience in a TPA or self-funded health plan environment
Knowledge of health insurance regulations and utilization management processes
Experience using medical necessity criteria and utilization review tools
Experience with EMRs and care management platforms
Mental health and/or substance use disorder (MH/SUD) case management experience
Multi-state licensure
Case management or utilization certifications (e.g., CCM, CPUR, CPHM)

Responsibilities

Identify members who would benefit from case management using claims data, referrals, and clinical records
Review referrals for clinical appropriateness using sound judgment and program parameters
Conduct comprehensive assessments of medical, behavioral, and social needs using a whole-person approach
Develop individualized care plans based on patient needs, barriers, and goals
Coordinate care across the continuum, including primary care, specialists, behavioral health, and community-based resources
Facilitate clear communication between patients, providers, caregivers, and health plans to support safe transitions of care and adherence to treatment plans
Provide telephonic case management for high-utilization patients with complex or chronic conditions
Use best practices in chronic disease management, motivational interviewing, and patient education
Advocate for timely, appropriate, and cost-effective care while balancing clinical judgment with plan guidelines
Support patients in navigating healthcare systems and overcoming barriers to care
Evaluate precertification requests using evidence-based criteria and plan-specific guidelines
Review ongoing inpatient stays and make length-of-stay determinations as appropriate
Partner with Appeals & Denials and/or in-house providers to support complex clinical decisions
Document all assessments, interventions, communications, and determinations thoroughly and accurately in ICM systems
Provide client-facing reports summarizing interventions, outcomes, and estimated cost savings
Ensure compliance with internal policies, regulatory requirements, and HIPAA standards
Partner with other clinical teams across ICM to remove care barriers and improve patient outcomes
Serve as a senior clinical resource, contributing to program development, cross-training, and process improvement
Stay current on best practices, regulations, and clinical guidelines related to case management
Participate in training, quality assurance initiatives, and professional development