Care Manager RN (Healthcare)

TL;DR

Care Manager RN (Healthcare): Implementing utilization management strategies and reviewing health care services to ensure appropriate resource utilization and quality of care. Focus on analyzing clinical data, educating providers and members, and facilitating interventions to improve health outcomes.

Location: Must be based in the United States (West Virginia)

Company

hirify.global is a national health and wellness organization providing health insurance and care delivery services.

What you will do

• Implement care management review processes consistent with industry and corporate standards.
• Review appropriateness of health care services and apply established criteria for resource utilization.
• Identify and refer members for Health Coaching or case management interventions.
• Educate providers and members to streamline processes and improve network relationships.
• Analyze qualitative and quantitative data to develop strategies for improving provider and member satisfaction.
• Ensure compliance with state and federal laws, including HIPAA regulations.

Requirements

• Current State of PA RN licensure OR current multi-state licensure through the eNLC.
• 3 years of related, progressive clinical experience in a clinical setting.
• Working knowledge of regulatory and compliance guidelines and medical policies.
• Strong analytical, organizational, and communication skills.
• Ability to multitask and perform in a fast-paced environment.
• Proficiency in computer software and data analysis.

Nice to have

• Bachelor’s Degree in Nursing.
• Certification in utilization management or a related field.
• Experience in UM/CM/QA/Managed Care.

Culture & Benefits

• Opportunity to work in a remote capacity.
• Commitment to ethical and legal standards in healthcare.
• Focus on professional development and collaborative team environment.