Nurse Care Mgr I
Remote
Telephonic RN Case Manager – Medicare/Geriatric Population
Schedule: Monday–Friday, 8:00 AM–5:00 PM in the employee’s local time zone
Employment Type: Hourly, overtime eligible
Work Setting: Telephonic care management
Position Summary
The Telephonic RN Case Manager supports Medicare members, primarily within a geriatric population, who have complex or chronic healthcare needs. This clinical role uses telephonic outreach, assessment, education, and care coordination to help members manage diseases, medications, treatment plans, and healthcare-related barriers.
The RN Case Manager collaborates with members, caregivers, providers, discharge planners, physician reviewers, and medical directors to promote medically appropriate, high-quality, cost-effective care and improved health outcomes.
Key Responsibilities
Conduct telephonic clinical assessments to identify members’ medical, psychosocial, functional, medication, and care-coordination needs.
Develop individualized care-management plans, measurable goals, and interventions for members with chronic and complex conditions.
Educate Medicare and geriatric members on disease self-management, medication adherence, preventive care, available benefits, and community resources.
Monitor member progress, evaluate the effectiveness of care plans, and revise interventions as clinical needs change.
Coordinate with healthcare providers to support transitions of care, discharge planning, follow-up services, and early intervention needs.
Review medical necessity and appropriateness of inpatient admissions, continued stays, outpatient services, out-of-network care, treatment setting, and level of care.
Partner with physician clinical reviewers and medical directors regarding clinical appropriateness, treatment planning, and care guidance.
Identify barriers to care, including transportation, caregiver support, medication access, health literacy, and social determinants of health.
Maintain timely, accurate clinical documentation in accordance with organizational, regulatory, and URAC requirements.
Ensure care-management activities are performed within the RN scope of practice and applicable state licensure requirements.
Required Qualifications
Active, unrestricted Registered Nurse license in the applicable state(s).
Multistate/compact RN license required when supporting members across multiple states.
High school diploma or equivalent.
At least 3 years of acute-care, direct clinical-care, or equivalent relevant nursing experience.
Prior case-management experience, including care planning, utilization review, discharge planning, or complex-care coordination.
Strong clinical assessment, critical-thinking, communication, and telephonic member-engagement skills.
Ability to work independently in a remote/telephonic environment while managing a caseload and meeting documentation expectations.
Preferred Qualifications
Experience supporting Medicare, geriatric, senior, or complex chronic-condition populations.
Home health, discharge planning, transition-of-care, utilization management, or care-coordination experience.
Associate’s or Bachelor’s degree in Nursing; BSN preferred.
Certified Case Manager (CCM) certification or similar case-management credential.
Five or more years of direct clinical-care experience.
Experience working in a managed-care, health-plan, payer, or URAC-accredited environment.
Ideal Candidate Profile
The ideal candidate is a clinically strong RN with case-management experience who is comfortable building rapport over the phone. They should understand the unique needs of elderly Medicare members and be able to guide them through disease management, medication concerns, post-discharge needs, provider follow-up, and access to appropriate services.