Care Manager RN (Medical)

TL;DR

Care Manager RN (Medical): Implementing utilization management strategies and reviewing healthcare services with an accent on resource utilization and quality issue resolution. Focus on monitoring healthcare delivery, educating providers and members, and maximizing patient outcomes through collaborative interventions.

Location: Remote (Must be based in Pennsylvania or hold a PA RN licensure / multi-state licensure through eNLC)

Company

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

What you will do

• Implement utilization management strategies to ensure appropriate resource utilization and health care service appropriateness.
• Perform care management reviews according to established industry standards, corporate policies, and regulatory guidelines.
• Identify and refer members for Health Coaching or case management interventions to enhance healthcare outcomes.
• Educate professional and facility providers and vendors to streamline processes and improve member satisfaction.
• Analyze qualitative and quantitative data to develop strategies for improving provider performance.
• Build and maintain positive working relationships with both internal and external customers.

Requirements

• Current State of PA RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• 3 years of related, progressive clinical experience in the area of specialization.
• Proven experience working in a clinical setting.
• Working knowledge of pertinent regulatory and compliance guidelines and medical policies.
• Strong analytical, organizational, and written/verbal communication skills.
• Proficiency in computer and software systems.

Nice to have

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

Culture & Benefits

• Remote work arrangement ("Working at Home").
• Professional environment centered on ethical principles and member privacy.
• Commitment to diversity, equity, and inclusion in the workplace.
• Collaborative team culture focused on quality and efficiency in care delivery.