Case Manager - Registered Nurse

ProviDRs Care•Wichita, KS

15h•Onsite

About The Position

The RN Case Manager provides comprehensive, member-centered case management to individuals covered by employer-sponsored, self-funded health plans administered by a third-party administrator (TPA). 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 for members while supporting quality care, appropriate resource utilization, and responsible management of health plan expenditures. The position is on-site 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. The RN Case Manager reports to the RN Supervisor / Director of Integrated Health Management and is part of the Integrated Health Management department. The role includes comprehensive assessment and care planning; care coordination and transitions of care; chronic disease education and support; medication reconciliation and pharmacy collaboration; utilization review and cost-containment collaboration; member advocacy and resource coordination; documentation and regulatory compliance; and interdisciplinary collaboration. The RN Case Manager maintains an assigned caseload, documents activities in an electronic case management system, participates in clinical meetings and quality improvement efforts, and performs other duties within the scope of professional nursing practice.

Requirements

Graduate of an accredited nursing program.
Active, unrestricted Registered Nurse (RN) license in Kansas or a valid multistate nursing license, as applicable.
Associate Degree in Nursing required.
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 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.
Develop, implement, and update individualized, measurable care plans and goals in collaboration with members and healthcare providers.
Monitor member progress, evaluate interventions, modify care plans as needed, and prioritize caseload interventions according to acuity, risk, and clinical complexity.
Coordinate services across primary care, specialty care, hospitals, rehabilitation facilities, home health agencies, and other settings.
Facilitate safe and timely 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 gaps in care and work 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 treatment adherence and appropriate follow-up.
Use motivational interviewing, teach-back, and other evidence-based approaches to encourage member engagement and self-management.
Perform medication reconciliation and identify adherence, duplication, access, affordability, and medication-related concerns.
Collaborate with PBMs, pharmacists, prescribers, and specialty pharmacy partners on medication therapy, alternatives, formulary requirements, specialty medications, and access issues.
Help members access medication assistance and affordability resources, and refer medication concerns to pharmacists or prescribing providers as appropriate.
Collaborate with UR Nurses and the Medical Director to identify members needing clinical support and review clinical, claims, and utilization information for case management opportunities.
Guide members toward appropriate, high-quality, cost-effective services and support safe, clinically appropriate use of healthcare resources.
Coordinate with Care Navigators regarding in-network providers, preferred facilities, and cost-saving programs; refer coverage and medical necessity questions to appropriate personnel.
Serve as a primary clinical resource for members, establish therapeutic relationships, and facilitate communication among members, caregivers, providers, and healthcare professionals.
Identify social and access barriers, connect members with community resources, respect member autonomy and confidentiality, and escalate urgent clinical or safety concerns.
Maintain accurate, 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 and information-security standards, and professional nursing standards.
Participate in audits, quality improvement initiatives, case reviews, interdisciplinary conferences, daily huddles, and departmental meetings.
Report quality-of-care concerns, patient safety issues, and compliance risks; communicate significant member concerns and barriers to appropriate team members.
Assist with developing and refining workflows, educational resources, and clinical protocols, and meet productivity and performance expectations.