Case Manager Registered Nurse
Job Location:
Salary:
Experience Required:
Posted:
Application Deadline:
Vacancies:
Job Summary
The RN Case Manager is responsible for providing comprehensive member-centered case management services to individuals covered under employer-sponsored self-funded health plans administered by the Third-Party Administrator (TPA).
This position focuses on identifying high-risk and high-cost members assessing clinical and psychosocial needs developing individualized care plans coordinating healthcare services and promoting appropriate cost-effective care.
The RN Case Manager works collaboratively with members healthcare providers Utilization Review (UR) Nurses Care Navigators Pharmacy Benefit Managers (PBMs) and other healthcare partners to improve health outcomes reduce avoidable healthcare utilization and support members in navigating the healthcare system.
The RN Case Manager serves as a clinical advocate for members while supporting the TPAs commitment to quality care appropriate resource utilization and responsible management of employer health plan expenditures.
Conduct comprehensive initial and ongoing assessments addressing medical conditions medications functional limitations behavioral health concerns and social determinants of health (SDOH).
Identify members who may benefit from case management through utilization reports claims data hospital admissions referrals and other available clinical information.
Evaluate members understanding of their diagnoses treatment plans medications and healthcare needs.
Develop implement and regularly update individualized measurable care plans in collaboration with members and their healthcare providers.
Establish short-term and long-term goals based on identified clinical needs and member priorities.
Monitor member progress evaluate interventions and modify care plans as necessary.
Maintain an assigned caseload and prioritize interventions according to member acuity risk and clinical complexity.
Coordinate healthcare services across primary care providers specialists hospitals rehabilitation facilities home health agencies and other healthcare settings.
Facilitate safe and timely transitions between levels of care including hospital discharge and post-acute care.
Conduct post-discharge outreach to assess member needs reinforce discharge instructions and identify potential complications.
Assist members with accessing appropriate providers diagnostic services durable medical equipment and community resources.
Identify gaps in care and facilitate interventions to reduce unnecessary emergency department visits hospitalizations and readmissions.
Collaborate with Care Navigators to address appointment scheduling provider access network utilization and nonclinical member needs.
Provide individualized education regarding chronic conditions treatment recommendations medications preventive care and lifestyle modifications.
Support members managing conditions such as diabetes hypertension cardiovascular disease chronic obstructive pulmonary disease and other complex medical conditions.
Promote adherence to recommended treatment plans and follow-up appointments.
Assess member readiness to change and identify barriers affecting self-management.
Utilize motivational interviewing teach-back methods and other evidence-based approaches to encourage member engagement.
Promote preventive screenings vaccinations and appropriate routine healthcare services.
Perform medication reconciliation and review prescribed medications for potential adherence concerns duplication access barriers and affordability issues.
Collaborate with Pharmacy Benefit Managers (PBMs) pharmacists prescribers and specialty pharmacy partners to support appropriate medication therapy.
Identify opportunities for clinically appropriate lower-cost medication alternatives in collaboration with prescribing providers and pharmacy professionals.
Assist members in accessing manufacturer patient assistance programs copay assistance and other available medication affordability resources.
Educate members regarding medication adherence administration potential adverse effects and the importance of follow-up monitoring.
Identify medication-related concerns requiring referral to a pharmacist or prescribing provider.
Coordinate with PBMs and pharmacy partners regarding specialty medications formulary requirements and medication access issues.
Collaborate with UR Nurses and the Medical Director to identify members requiring additional clinical support.
Review available claims utilization and clinical information to identify potentially avoidable healthcare expenditures.
Identify opportunities to guide members toward appropriate high-quality cost-effective healthcare services.
Coordinate with Care Navigators regarding in-network providers preferred facilities and available cost-saving programs.
Support appropriate utilization of healthcare resources while maintaining member safety and clinical quality.
Identify high-cost treatment episodes and complex care needs requiring proactive case management intervention.
Assist in coordinating alternative treatment settings when clinically appropriate and consistent with plan benefits.
Refer coverage or medical necessity questions to the appropriate UR or benefits administration personnel.
Serve as a primary clinical resource for members enrolled in case management.
Establish therapeutic relationships through compassionate professional and culturally responsive communication.
Identify barriers related to transportation housing food insecurity financial limitations health literacy and access to healthcare.
Connect members with appropriate community resources and support services.
Facilitate communication among members caregivers providers and other healthcare professionals.
Respect member autonomy confidentiality and informed decision-making.
Escalate urgent clinical concerns and safety issues according to established protocols.
Maintain complete accurate and timely documentation of assessments care plans member interactions interventions and outcomes.
Document case management activities in the designated electronic case management system.
Maintain compliance with HIPAA applicable ERISA requirements state and federal regulations and organizational policies.
Follow established confidentiality information security and professional nursing standards.
Participate in internal audits quality improvement initiatives and case reviews.
Identify and report potential quality-of-care concerns patient safety issues and compliance risks.
Maintain appropriate documentation supporting case management outcomes and program effectiveness.
Participate in interdisciplinary case conferences and clinical team meetings.
Collaborate with RN Utilization Review Nurses Care Navigators the Medical Director and department leadership.
Communicate significant member concerns high-risk situations and barriers to care to appropriate team members.
Participate in daily huddles departmental meetings and performance improvement initiatives.
Assist with development and refinement of case management workflows educational resources and clinical protocols.
Maintain productivity and performance expectations established by department leadership.
Perform other duties as assigned within the scope of professional nursing practice.
Unified Health Plan offers a competitive compensation and benefits package designed to support the health financial well-being and work-life balance of our employees.
Our benefits package may include:
Competitive salary based on qualifications and experience
Comprehensive medical dental and vision insurance
Company-sponsored life insurance
Short-term and long-term disability coverage
401(k) retirement savings plan with employer matching
Paid time off (PTO)
Paid company holidays
Supportive team-oriented work environment
Consistent MondayFriday work schedule
Required Skills:
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 while collaborating effectively with an interdisciplinary team. Strong understanding of professional boundaries confidentiality and ethical nursing practice.
Required Education:
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; Bachelor of Science in Nursing (BSN) preferred.
