Case Manager Nurse- RN

Overview Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities Ready to Job Summary As a Case Manager RN, you will provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. May be required to work evening and/or weekend shifts. What You'll Actually Do Essential Functions/Responsibilities/Duties Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs. Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs. Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals. Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions. Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care. Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance. Be able to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis. Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports. Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance and information. Evaluate and make referrals for wellness programs. Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90 days interval for low-risk cases ensuring confidentiality according to Company policy and HIPAA Perform Utilization Review for assigned members. Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issues. Qualifications What You Bring to Our Team Education and Experience Required Knowledge, Skills, and Abilities Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Ability to critically evaluate claims data and determine treatment plan, discharge planning experience. Ability to work independently making decisions and problem solving Knowledge of community resources and alternate funding programs. Computer proficiency or working knowledge of Microsoft Office Suite. Excellent interpersonal, communication and negotiation skills. Strong customer orientation. Good time management skills and highly organized. Work Environment At Personify Health we value and celebrate diversity, and we are committed to creating an inclusive environment for all employees. We believe in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce better solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. Physical Requirements Must be able to remain in a stationary position 50% of the time. The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities. Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. Frequently positions self to maintain files in file cabinets. Frequently moves boxes or equipment weighing up to 25 pounds. Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations. Must be able to observe details at close range. Disclaimer This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role within the company. Activities, duties, and responsibilities are subject to change at any time with or without notice. Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $36-$37 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected]. View all legitimate openings at personifyhealth.com/careers.