Medical Case Manager

• Manage a caseload of members with moderate-complexity health needs
• 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
• Coordinate referrals to specialists and community 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
• Collaborate and communicate with physicians, providers, co-workers, and healthcare team members
• Document activities in compliance with business processes, company policies, regulatory requirements, and accreditation standards
• Identify potential cost savings, quality improvements, and workflow efficiencies
• Perform other duties as assigned or requested

Requirements

• 3 years of experience in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience with RN licensure or a Master’s degree
• 5 years’ experience with a Bachelor’s in Social Work
• Bachelor’s degree in nursing or RN licensure or Master’s degree in Social Work, Counseling, or related field, OR Bachelor’s degree in Social Work
• Required professional license/certification: LSW, LPC, LBSW, LCSW, LMSW, LGSW, LCSW, or current State RN licensure, or current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Strong assessment and care planning skills
• Ability to work independently and as part of a team
• Proficiency in Microsoft Office Suite, case management software, and electronic health records
• Understanding of healthcare systems and case management principles
• Bilingual English/Spanish language skills preferred
• Telephonic experience preferred
• Medicaid managed care and/or Medicare experience preferred
• Experience working with the healthcare needs of diverse populations preferred
• Experience demonstrating understanding of cultural competency preferred
• Certified Case Manager (CCM) preferred
• Must comply with HIPAA, data security guidelines, company policies, legal requirements, and accreditation standards

Core Competencies

Demonstrates strong assessment and care planning skills while managing a caseload of members with moderate-complexity health needs. Proficient in coordinating care plans, collaborating with healthcare teams, and ensuring compliance with regulatory requirements.

Highest-signal resume keywords

• RN Licensure
• Case Management Software
• Assessment Skills
• Care Planning
• Bilingual English/Spanish

ATS Optimization Keywords

Hard Skills

• Care Coordination
• Health Needs Assessment
• Individualized Care Plans
• Monitoring Member Progress
• Evaluating Interventions
• Cost Savings Identification
• Cultural Competency
• Telephonic Experience
• Medicaid Managed Care
• Medicare Experience

Soft Skills

• Team Collaboration
• Independent Work
• Advocacy

Certifications & Qualifications

• Certified Case Manager (CCM)
• LSW
• LPC
• LBSW
• LCSW
• LMSW
LGSW

Industry Keywords

• Healthcare Systems
• Case Management Principles
• Regulatory Compliance
• Accreditation Standards
• Diverse Populations

Tools & Technologies

• Microsoft Office Suite
• Electronic Health Records