Care Manager RN - Medicaid (Remote)

Location: Working from home in Pennsylvania (PA)

Company

hirify.global provides healthcare and health insurance services, including Medicaid care management.

What you will do

• Conduct utilization and care management reviews using established criteria, medical policies, and regulatory standards.
• Monitor and analyze healthcare service delivery, outcomes data, provider performance, and member satisfaction.
• Identify members who may benefit from health coaching or case management and coordinate collaborative interventions.
• Educate members, professional and facility providers, and vendors on care options and streamlined processes.
• Respond to customer inquiries, recommend interventions or alternatives, and address quality issues.
• Maintain compliant, ethical, and privacy-protective care management practices under applicable laws and HIPAA requirements.

Requirements

• At least 3 years of progressive clinical experience in the relevant specialty and experience in a clinical setting.
• Current Pennsylvania RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC) is required.
• Additional state licensure may be required depending on where clinical care is provided.
• Working knowledge of regulatory and compliance guidelines, medical policies, and care management standards.
• Strong written and verbal communication, analytical, organizational, prioritization, and deadline-management skills.
• Ability to multitask effectively in a fast-paced environment and use computer and software tools proficiently.

Nice to have

• Bachelor’s degree in Nursing.
• Experience in utilization management, care management, quality assurance, or Medicaid managed care.
• Certification in utilization management or a related field.

Culture & Benefits

• Remote work arrangement from Pennsylvania.
• Travel requirement of 0%–25%.
• Work includes protecting confidential customer and health information under HIPAA and company security policies.
• Work is performed within applicable federal and state laws, ethical standards, and company policies.