Case Manager - Registered Nurse

ProviDRs Care•Wichita, KS

1d•Onsite

About The Position

The RN Case Manager provides comprehensive, member-centered case management to people covered by employer-sponsored, self-funded health plans administered by a third-party administrator. The role identifies high-risk and high-cost members, assesses clinical and psychosocial needs, develops individualized care plans, coordinates healthcare services, and promotes appropriate, cost-effective care. The RN Case Manager collaborates with members, providers, utilization review nurses, care navigators, pharmacy benefit managers, and other healthcare partners to improve outcomes, reduce avoidable utilization, and help members navigate the healthcare system. The position serves as a clinical advocate while supporting quality care, responsible resource utilization, and management of employer health plan expenditures. This is an on-site position in Wichita, Kansas, in a professional office environment. The schedule is Monday through Friday, either 8 a.m.–5 p.m. or 10 a.m.–7 p.m. Work involves frequent telephone communication, computer use, and electronic documentation; prolonged sitting; and occasional standing and walking. The role requires maintaining confidentiality while discussing sensitive member information and performing essential functions with or without reasonable accommodation. The RN Case Manager is expected to demonstrate clinical professionalism, accountability, sound nursing judgment, and commitment to member-centered care. Success requires balancing clinical quality, member advocacy, effective resource utilization, and the operational objectives of a self-funded health plan TPA.

Requirements

Graduate of an accredited nursing program.
Associate Degree in Nursing required.
Active, unrestricted Registered Nurse license in Kansas or a valid multistate nursing license, as applicable.
At least three years of clinical nursing experience.
Experience in medical-surgical nursing, discharge planning, care coordination, chronic disease management, or a related clinical setting.
Strong clinical assessment, critical thinking, and nursing judgment skills.
Excellent verbal and written communication skills.
Ability to manage multiple cases and competing priorities effectively.
Strong organizational, time management, and documentation skills.
Ability to establish rapport with members and healthcare professionals.
Knowledge of chronic disease management and evidence-based clinical practices.
Ability to interpret clinical information and identify opportunities for intervention.
Proficiency with electronic health records, case management software, Microsoft Office, and related applications.
Ability to work independently and collaborate effectively with an interdisciplinary team.
Strong understanding of professional boundaries, confidentiality, and ethical nursing practice.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Prior case management experience.
Experience working for a TPA, health insurance company, managed care organization, or self-funded employer health plan.
Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification.
Experience managing members with complex medical conditions and high healthcare utilization.
Familiarity with self-funded health plans, ERISA, provider networks, and healthcare benefit structures.
Knowledge of pharmacy benefit management and medication assistance programs.
Experience with electronic case management systems, claims data, and utilization reporting.
Understanding of clinical quality measures, population health, and healthcare cost-containment strategies.

Responsibilities

Conduct comprehensive initial and ongoing assessments of members’ medical conditions, medications, functional limitations, behavioral health concerns, and social determinants of health.
Identify members who may benefit from case management using utilization reports, claims data, hospital admissions, referrals, and other clinical information.
Assess members’ understanding of diagnoses, treatment plans, medications, and healthcare needs.
Develop, implement, and update individualized, measurable care plans and goals in collaboration with members and providers.
Monitor member progress, evaluate interventions, modify care plans as needed, and prioritize caseload work according to acuity, risk, and complexity.
Coordinate care across primary care, specialty, hospital, rehabilitation, home health, and other settings.
Facilitate safe transitions between levels of care, including hospital discharge and post-acute care, and conduct post-discharge outreach.
Help members access providers, diagnostic services, durable medical equipment, and community resources; identify care gaps and interventions to reduce avoidable emergency visits, hospitalizations, and readmissions.
Collaborate with Care Navigators on appointment scheduling, provider access, network utilization, and nonclinical needs.
Educate members about chronic conditions, treatment recommendations, medications, preventive care, and lifestyle modifications; promote adherence and preventive services.
Use motivational interviewing, teach-back, and other evidence-based approaches to support engagement and self-management.
Perform medication reconciliation and identify adherence, duplication, access, affordability, and other medication-related concerns.
Collaborate with PBMs, pharmacists, prescribers, and specialty pharmacy partners on medication therapy, affordability resources, specialty medications, formulary requirements, and access issues.
Work with UR Nurses and the Medical Director to identify members needing clinical support and review available claims, utilization, and clinical information for potentially avoidable expenditures.
Guide members toward appropriate, high-quality, cost-effective services; support appropriate resource use while maintaining safety and quality; and help coordinate alternative treatment settings when clinically appropriate and consistent with plan benefits.
Refer coverage or medical necessity questions to appropriate utilization review or benefits administration personnel.
Serve as a primary clinical resource for members, establish therapeutic relationships, and communicate compassionately, professionally, and culturally responsively.
Identify barriers such as transportation, housing, food insecurity, financial limitations, health literacy, and healthcare access, and connect members with community resources and support services.
Facilitate communication among members, caregivers, providers, and other healthcare professionals; respect autonomy, confidentiality, and informed decision-making; and escalate urgent clinical and safety concerns according to protocols.
Maintain accurate and timely documentation of assessments, care plans, interactions, interventions, and outcomes in the designated electronic case management system.
Comply with HIPAA, applicable ERISA requirements, state and federal regulations, organizational policies, confidentiality requirements, information security rules, and professional nursing standards.
Participate in audits, quality improvement initiatives, case reviews, interdisciplinary conferences, clinical team meetings, daily huddles, and departmental meetings.
Report quality-of-care concerns, patient safety issues, compliance risks, significant member concerns, high-risk situations, and barriers to care to appropriate team members.
Maintain documentation supporting outcomes and program effectiveness, meet productivity and performance expectations, and assist with improving workflows, educational resources, and clinical protocols.
Perform other duties as assigned within the scope of professional nursing practice.