Case Manager

Job Title: RN Case Manager

Hiring Manager: Karen Grijalva

Program: Complex Case Management

Employment Type: Temporary / Pilot Program

Location: Remote - 28 approved states; preference for North Carolina

Schedule: Monday-Friday, 8:00 AM-5:00 PM EST

Hours: 40 hours/week

Experience: 3-5 years

Position Overview: We are seeking an experienced Registered Nurse (RN) Case Manager to support a Complex Case Management Program. The Case Manager will provide comprehensive, member-centered case management services, assess member needs, coordinate care across the healthcare continuum, and develop individualized plans to improve health outcomes while helping manage healthcare costs. This is primarily a telephonic case management role requiring strong clinical judgment, communication, organization, and time-management skills. The ideal candidate will have experience working with complex patients, preferably in a hospital or health insurance case management environment.

Key Responsibilities: Conduct comprehensive clinical assessments and determine appropriate interventions and care plans for members. Develop individualized, member-centered care plans based on health status, needs, education, available support, and identified barriers. Coordinate with members, families, physicians, internal teams, community resources, and external healthcare providers. Perform ongoing telephonic monitoring and case management, including follow-up calls, education, referrals, and progress assessments. Coordinate and evaluate care across the healthcare continuum, including hospitals, physician offices, rehabilitation facilities, skilled nursing facilities, and home care. Prioritize and follow up with members who have recently been discharged from the hospital. Identify and provide outreach to high-risk, high-cost, or high-utilization members. Educate members regarding their conditions, treatment plans, available resources, and proactive interventions. Identify barriers to achieving treatment goals and develop strategies to address them. Utilize community resources and funding sources when developing and implementing care plans. Make appropriate referrals and ensure all supporting documentation is completed. Monitor member progress and modify care plans and goals based on changing needs and acuity. Evaluate medical necessity and appropriateness of services when required. Review alternative treatment plans and assess benefit exceptions or flexible benefit options when applicable. Maintain accurate and timely documentation throughout the assessment, planning, implementation, monitoring, and evaluation process. Collaborate effectively with internal and external stakeholders to ensure continuity of care. Develop policies, procedures, educational materials, or training resources when needed.

Required Qualifications: Active Registered Nurse (RN) license required. Valid North Carolina or compact multi-state RN license. Minimum 3 years of clinical and/or case management experience. Hospital or clinical experience strongly preferred. Strong clinical assessment and care coordination skills. Excellent verbal and written communication skills. Strong telephone etiquette and member engagement skills. Strong organizational and time-management abilities. Ability to manage multiple cases and prioritize work based on member acuity and urgency.

Preferred Qualifications: Certified Case Manager (CCM) certification preferred. Previous telephonic case management experience. Experience working with Medicare populations. Previous health insurance case management experience. Experience with complex, high-risk, high-cost, or high-utilization members. Strong technical/computer skills and ability to learn new systems quickly. Technology-savvy with the ability to navigate multiple systems and documentation platforms.

Typical Day: The Case Manager will begin the day at 8:00 AM EST by reviewing assigned cases and prioritizing members based on clinical needs. Priority is generally given to members who have recently been discharged from the hospital, followed by outreach to other assigned members. The majority of the position involves telephone-based member engagement, including assessments, follow-up calls, education, care coordination, referrals, and documentation. Strong time-management and organizational skills are essential due to the volume of cases and the need to prioritize members appropriately.

Training: Selected candidates will receive approximately one month of training to learn the organization's processes, systems, and case management procedures before independently managing their caseload.

Team & Work Environment: The Case Manager will work closely with internal clinical and operational teams as well as members, families, physicians, healthcare providers, and community resources. The team holds biweekly meetings to collaborate, share information, discuss cases, and ask questions. First 90 DaysThe primary focus during the first 90 days will be to: Successfully complete training and become proficient with organizational processes and systems. Develop an understanding of complex case management workflows. Effectively prioritize and manage assigned cases. Conduct high-quality member outreach and clinical assessments. Establish strong documentation and care coordination practices. Demonstrate the ability to independently manage a caseload while meeting quality and productivity expectations.