Remote RN Case Manager

Job Description

WHAT YOU'LL BE DOING 

The Registered Nurse (RN) Case Manager enhances the quality and effectiveness of member care management by promoting wellness, improving satisfaction, and supporting cost-effective outcomes. This role partners collaboratively with members, providers, and clients to help individuals navigate the healthcare system and achieve personal health-related goals.

The RN Case Manager performs telephonic outreach, clinical assessments, data analysis, documentation, and reporting in compliance with federal and state regulations, NCQA standards, and company policies. This position plays a critical role in population health and value-based care initiatives.

• Analyze, sort, and interpret data to determine member eligibility for Population Health Management programs.
• Coordinate and deliver timely, effective, equitable, safe, and member-centric care in accordance with HMO processes.
• Manage assigned caseloads, including outreach, documentation, monitoring case progression, and case closure.
• Conduct telephonic outreach to members and providers to support care coordination and engagement.
• Perform clinical reviews and complete medical and behavioral health assessments.
• Address barriers to care by identifying social determinants of health, psychosocial issues, and member motivators.
• Educate members on navigating the HMO and broader healthcare system to promote informed decision-making.
• Promote quality, cost-effective interventions and outcomes.
• Meet all reporting and documentation standards while participating in collaborative meetings with internal teams and clients.
• Support operational initiatives to meet organizational goals, customer requirements, and satisfaction metrics.
• Maintain strict confidentiality of medical records, data, and all computer-based systems.
• Participate in Quality Management (QM) and Utilization Management (UM) committee meetings, as applicable, including preparation, documentation, data analysis, reporting, and follow-up (may require in-person attendance).
• Participate in off-hour and weekend call rotations, if applicable.
• Maintain continued professional development in accordance with the Illinois Nurse Practice Act.
• Perform additional duties as assigned and in alignment with annual program requirements.

What Success Looks Like

Within 3 Months

• Work primarily autonomously on daily assignments with routine daily or weekly interaction and oversight from a preceptor.
• Demonstrate foundational knowledge of the UM/PHM plan, MSA, processes, resources, EMR systems, and documentation platforms.
• Independently conduct telephonic outreach, documentation, and log reviews.
• Develop emerging skills in reporting and cross-departmental communication with clinical teams.

Within 6 Months

• Independently prepare for and present in UM meetings, if applicable.
• Perform daily responsibilities efficiently and in alignment with departmental processes and UM/PHM plans.
• Communicate professionally and effectively with members, providers, clients, and internal departments.
• Build rapport with members and stakeholders through telephonic engagement.

Within 12 Months

• Demonstrate advanced collaboration skills in reporting and cross-functional communication.
• Maintain in-depth knowledge of HMO products, departmental processes, MSAs, and UM/PHM plans, including annual changes.
• Develop comprehensive knowledge of contracted Independent Practice Associations (IPAs) and support coverage across IPAs as needed.
• Contribute to departmental process development and continuous improvement initiatives.
• Exhibit forward-thinking problem-solving skills with an understanding of productivity, incentives, departmental goals, and outcomes.