Case Manager Nurse RN

Personify Health•Remote,

5d•$34 - $36•Remote

About The Position

When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale.

Requirements

Graduate of an accredited Registered Nursing (RN) program
Current California RN license required; multi-state license also required
Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience
Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management
Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding
Ability to critically evaluate claims data to inform treatment and discharge planning
Knowledge of community resources and alternate funding programs
Proficiency with Microsoft Office Suite
Working knowledge of case management platforms such as Eldorado and UM Web

Responsibilities

Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture.
Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs.
Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals.
Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working.
Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care.
Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses.
Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports.
Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines.
Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate.
Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA.
Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making.