Case Manager RN

1w1 week ago

Personify Health

US · Full-time · $72,000 – $76,000

About this role

Personify Health created the first and only personalized health platform because health is personal. It brings 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 improving health outcomes.

As a Case Manager RN, provide telephonic case management between providers, patients, and caregivers. Ensure cost-effective, high-quality healthcare for health insurance plan participants. May require evening and/or weekend shifts.

Contact patients to complete thorough assessments including physical, psychosocial, emotional, spiritual, environmental, and financial needs. Use claims processing tools to review paid claim data and develop clinical pictures. Collaborate with patients, caregivers, community resources, and multidisciplinary providers on treatment plans.

Monitor interventions, evaluate treatment plan effectiveness, and report measurable outcomes. Initiate and maintain contact throughout the care continuum while advocating for patients. Negotiate cost management strategies and maintain detailed documentation per HIPAA.

Serve as mentor to LVNs providing guidance on complicated cases. Establish relationships with healthcare providers, clients, and patients for support and information. Perform utilization review and make wellness program referrals.

Requirements

Graduation from an accredited Registered Nursing (RN) program
Possession of a current California RN license; a multi-state license will also be required
Minimum of five (5) years medical/surgical or acute care experience, including two years’ experience in case management
Prior case management experience, emergency room, critical care background or other relevant clinical care experience
Ability to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis
Experience negotiating and implementing cost management strategies
Ability to evaluate and make referrals for wellness programs

Responsibilities

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
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers, family, community resources and multi-disciplinary healthcare providers
Monitor interventions and evaluate the effectiveness of the treatment plan; report measurable outcomes
Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team throughout the continuum of care
Advocate for the patient by facilitating the delivery of quality patient care and reducing overall costs
Maintain complete and detailed documentation of case managed patients ensuring confidentiality according to Company policy and HIPAA
Perform Utilization Review for assigned members and serve as mentor to LVNs on complicated cases