Care Manager RN

TL;DR

Care Manager RN: Implementing utilization management and care management review processes to ensure appropriate health care service delivery with an accent on quality issues, provider performance, and member satisfaction. Focus on applying clinical criteria, analyzing qualitative/quantitative outcomes data, and coordinating interventions through Health Coaching/case management.

Company

hirify.global provides healthcare services and related programs.

What you will do

• Conduct care management review processes aligned with industry and corporate standards within the RN’s professional discipline.
• Apply accepted criteria, guidelines, and medical policies to ensure appropriate resource utilization.
• Identify members who may benefit from Health Coaching/case management interventions and coordinate collaborative care actions.
• Monitor and analyze delivery of health care services, using qualitative and quantitative outcomes data to improve provider and member satisfaction.
• Educate providers and members on proactive care options and available provider resources.
• Respond to customer inquiries and provide interventions and/or alternatives while maintaining member privacy.

Requirements

• Location: Working in Pennsylvania (PA)
• 3 years of related, progressive clinical experience in the area of specialization, including experience in a clinical setting.
• Licensure: Current PA RN licensure OR current multi-state licensure via the enhanced Nurse Licensure Compact (eNLC)
• Working knowledge of regulatory/compliance guidelines and medical policies.
• Strong written and verbal communication skills; ability to analyze data, measure outcomes, and develop action plans.
• Ability to multitask in a fast-paced, often intense environment and prioritize work to meet deadlines.

Culture & Benefits

• Office-based role with occasional travel to work sites (0%–25% travel requirement).
• Compliance-focused environment with HIPAA and privacy/security expectations for covered information.
• Emphasis on quality and efficiency in care management services.
• Collaboration with internal and external customers to support member outcomes.

Hiring process

• Interviews to assess clinical experience, utilization/case management knowledge, and communication skills.
• Evaluation of ability to apply criteria/guidelines and analyze outcomes data to drive action plans.