Care Manager, RN – CW

TALENT Software Services; Pittsburgh (Allegheny County); On-site; USD 75,000 - 110,000; Full time

Job summary

TALENT Software Services is seeking a Senior Nurse Case Manager in Pennsylvania. The role focuses on managing complex member health needs, performing telephonic assessments, and coordinating care with providers to support self-management and access to resources.

Strong communication and documentation skills are essential for success. Responsibilities include developing care plans, maintaining regular member contact, and collaborating with Benefits and clinical teams to ensure accurate claims,

Qualifications

• Must have 5+ years of relevant experience.
• Must be a currently licensed RN in the state of PA.
• Disease Management knowledge or experience.
• Certified Case Manager preferred.
• Prior experience in case management and managed care.
• Knowledge of assessments and care plans.
• Experience with community resources.
• Some knowledge of preventive health services.
• 1-800-line experience preferred.
• Experience with Medicaid population.

Responsibilities

• Function as a primary clinician for members with complex health needs, from coaching to intensive case management.
• Conduct telephonic clinical assessments to support self-management and behavior change.
• Develop plans of care with short- and long-term goals.
• Establish regular telephonic contact to review progress.
• Coordinate with treating providers and educate other clinicians as needed.
• Identify community resources to support health goals.
• Incorporate lifestyle improvement opportunities into member interactions.
• Document all activities in compliance with regulatory standards.
• Coordinate services and benefits with internal teams as needed.

Skills

Nursing assessment

Care coordination

Telephonic outreach

Verbal & written communication

Self-management coaching

Education

RN license PA

CCM certification (preferred)

Job description

Responsibilities

• Function as a primary clinician for members with complex health needs, with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services, the goal is always to help develop and support the member's ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision-making.
• Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills to effect members' self-management and positive behavior changes.
• Develop case or condition-specific plans of care using the clinical information system to establish short- and long-term goals.
• Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs.
• Communicate with the member's treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated.
• Identify online, telephonic, and community-based resources that can assist the member to achieve and maintain their personal health goals and assist the member to access those services.
• Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
• Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements, and accreditation standards.
• Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable. Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

Must have

• 5+ years of relevant experience
• Must be a currently licensed RN in the state of PA
• Disease Management knowledge or experience
• Certified Case Manager preferred
• Prior experience working in case management and managed care
• Knowledge of assessments and care plans
• Experience with community resources
• Some knowledge of preventive health services
• 1-800-line experience preferred
• Experience working with the Medicaid population
• Must have a great work ethic
• Able to work independently
• Telephonic outreach to members
• Excellent verbal and written communication skills
• The manager is looking for candidates with experience with Disease Management. The candidates must be nurses with strong assessment skills for care coordination and education of members for their Disease Management program. Past Case Management, telephonic experience, and Medicaid knowledge are pluses. Please work to identify new candidates who meet these experience requirements.
• Must have a PA nursing license,
• CCM preferred

Disease Management Experience Preferred

• Telephonic Case Management experience preferred