Care Manager RN (Healthcare)

TL;DR

Care Manager RN (Healthcare): Implementing utilization management strategies and reviewing the appropriateness of healthcare services with an accent on resource utilization and quality issue resolution. Focus on educating providers, analyzing healthcare delivery data, and maximizing member health outcomes through collaborative interventions.

Location: Must be based in Pennsylvania (Remote/Hybrid setup with potential travel to work sites)

Company

hirify.global is a leading healthcare organization providing insurance and health services.

What you will do

• Implement utilization management strategies to ensure appropriate resource utilization and healthcare service appropriateness.
• Perform care management reviews according to industry standards, corporate policies, and regulatory compliance.
• Identify members for Health Coaching or case management interventions to improve healthcare outcomes.
• Educate professional providers and vendors to streamline processes and develop network relationships.
• Analyze qualitative and quantitative data to develop strategies for improving provider and member satisfaction.
• Collaborate with internal and external customers to facilitate maximal member health outcomes.

Requirements

• Current State of PA RN licensure OR multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Minimum 3 years of related, progressive clinical experience in the area of specialization.
• Experience working within a clinical setting.
• Working knowledge of regulatory and compliance guidelines and medical policies.
• Strong analytical, organizational, and communication skills.

Nice to have

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

Culture & Benefits

• Flexible work arrangement supporting working from home within Pennsylvania.
• Collaborative environment focused on member-centric care and ethical principles.
• Opportunities to influence quality of care and provider performance through data-driven strategies.