Case Manager/RN
About The Position
We are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industry, we believe in fostering a collaborative, inclusive and supportive work environment where every team member is valued and empowered to make a difference. Whether you're an experienced professional or just starting your career, we offer opportunities for growth, development, and advancement in a range of roles. Join us in our mission to enhance the well-being of our patients and residents while making a meaningful impact in the communities we serve. Are you a licensed healthcare professional skilled at bridging the gap between patient care, clinical necessity, and payor navigation? As an Internal Case Manager, you will play a central role in driving quality, cost-effective patient outcomes. You will lead the collaborative process of assessment, utilization management, advocacy, and discharge planning—ensuring every patient receives the care they need while protecting against financial risks and unreimbursed claims.
Requirements
- Must be a graduate of an approved school of nursing with a license as a Registered Nurse or equivalent professional license (Physical Therapist, Occupational Therapist, Speech Therapist, Licensed Social Worker or Master of Social Work).
- Five years of recent clinical nursing experience required.
- Prior experience in utilization review, case management or discharge planning required.
- Prior experience using evidence-based clinical decision support criteria (e.g.Interqual, Milliman)
- Advanced knowledge of third-party reimbursement, insurance coverage and contract requirements.
Nice To Haves
- Bachelor’s degree in nursing preferred.
- Certified Case Management (CCM) or related clinical certifications are also preferred.
- Experience in rehabilitation nursing, acute care and/or the insurance field is preferred.
- Two years’ full-time experience in case management, which includes service to short/long-term facility-based residents, is preferred.
Responsibilities
- Verify, document, and submit complete clinical data to payors from pre-admission through concurrent review (using PointClickCare and NetHealth) to justify medical necessity.
- Negotiate level of care (LOC), length of stay (LOS), daily rates, and service extensions. Secure approvals for procedures, treatments, equipment, and non-formulary medications.
- Serve as the clinical reimbursement resource for physicians, nurse practitioners, social workers, MDS coordinators, and rehab directors to align care plans with contract terms.
- Monitor cases for service over/under-utilization to prevent claim denials. Assist with clinical appeals and ensure timely delivery of Notices of Non-Coverage.
- Identify risk factors, chronicity, and barriers to discharge early. Partner with network providers and local staff to ensure safe, seamless patient transitions.
Benefits
- Tuition, Travel, Wireless Service, and Other Discounts
- Employee Assistance Program to support mental health
- Employee Foundation to financially assist through unforeseen hardships
- Health, Dental, Vision, Company-paid life insurance, 401K, Paid Time Off
- Free 24/7 virtual health care provided by licensed doctors for all Anthem medically enrolled employees and their immediate family members
- On-Demand Pay Program that allows for instant access to a portion of the money you’ve already earned
- Pet Insurance
- Term and Whole Life Insurance
- Short-term Disability
- Hospital Indemnity
- Personal Accident
- Critical Illness
- Cancer Coverage
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What This Job Offers
Job Type
Full-time
Career Level
Senior
