Senior Case Manager, RN

• Manage a caseload of members with complex health needs
• Conduct comprehensive assessments and develop complex care plans
• Assess members’ health status, needs, and available resources
• Develop individualized care plans with members, physicians, and healthcare providers
• Implement and coordinate care plans and access to appropriate services and resources
• Monitor member progress and adjust care plans as needed
• Evaluate the effectiveness of interventions and services
• Advocate and act as a liaison to meet members’ individual healthcare needs
• Promote quality, cost-effective outcomes in accordance with contract benefits
• Detect, resolve, and prevent improper utilization of member benefits
• Collaborate and communicate with physicians, providers, co-workers, and healthcare team members
• Document activities in compliance with business, company, regulatory, and accreditation requirements
• Provide guidance and mentorship to lower-level Case Managers
• Serve as a resource for clinical expertise and problem-solving
• Perform other duties as assigned or requested

• 5 years in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience
• High School/GED
• Current State RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Certified Case Manager (CCM) certification must be obtained within 36 months of hire; incumbents in the role as of August 2026 are exempt
• Expertise in clinical assessment and care planning
• Strong leadership and mentoring skills
• Excellent negotiation and advocacy skills
• Proficiency in Microsoft suite of applications, case management software, and electronic health records
• Strong understanding of healthcare systems and case management principles
• Ability to work with physicians, providers, co-workers, and other healthcare team members
• Compliance with applicable business process requirements, company policies, regulatory requirements, accreditation standards, HIPAA, privacy, information security, and code of business conduct requirements

Demonstrates expertise in clinical assessment, care planning, and case management principles while effectively collaborating with healthcare teams to advocate for members' healthcare needs. Proficient in compliance with regulatory requirements and skilled in mentoring and leadership within a clinical setting.

• Clinical Assessment
• Care Planning
• Certified Case Manager (CCM)
• Leadership and Mentoring
• Healthcare Systems Knowledge

• Clinical Assessment
• Care Planning
• Case Management Principles
• Utilization Management
• Disease Condition Management

• Negotiation Skills
• Advocacy Skills
• Collaboration Skills

• Current State RN Licensure
• Certified Case Manager (CCM)

• Healthcare
• Regulatory Compliance
• Accreditation Standards
• HIPAA
• Information Security

• Microsoft Suite
• Case Management Software
• Electronic Health Records