Case Manager Nurse RN

Personify Health; California (MO); Hybrid; USD 4,822,000 - 5,510,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Mental health support

Retirement planning

Career development

Diversity & inclusion

Job summary

Personify Health is seeking a Case Manager RN in California to guide patients through their treatment plans. You will assess clinical needs, review claims data, and collaborate with providers and families to ensure appropriate, timely care.

This is a patient-centered, outcomes-driven role within a team that values cost-effective healthcare at scale. Ideal candidates hold CA RN licensure with multi-state eligibility and have 5+ years in medical/surgical or acute care, including case management

Qualifications

• RN license required in California, multi-state license preferred.
• Minimum 5 years medical/surgical or acute care experience, with 2 years in case management.
• Experience with case management, emergency room, or critical care is valued.

Responsibilities

• Assess the whole patient: conduct thorough assessments across domains to build a clinical picture.
• Mine claims data for insight using processing tools to identify candidates for case management.
• Develop individualized treatment plans for standard and catastrophic cases with stakeholders.
• Track outcomes and adjust the care plan; report measurable results.
• Maintain ongoing communication with patients, families, and care teams throughout care.
• Advocate for patients to access quality care and reduce costs.
• Drive cost management strategies and reflect impact in reviews.
• Perform utilization review to ensure alignment with guidelines.
• Refer patients to wellness resources when appropriate.
• Maintain confidential documentation and prepare reports per policy and HIPAA.
• Mentor LVN colleagues as a clinical resource.

Skills

Claims data analysis

Clinical assessment

Care navigation

Microsoft Office

Eldorado

UM Web

Education

California RN license

Multi-state license

Tools

Eldorado

UM Web

Microsoft Office

Job description

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing 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 actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Ready to be the difference between a confusing diagnosis and a clear path forward?

Why This Role Matters

When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale.

What You'll Actually Do

• Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture.
• Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs.
• Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals.
• Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working.
• Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care.
• Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses.
• Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports.
• Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines.
• Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate.
• Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA.
• Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making.

What You Bring to Our Team

Education & Experience:

• Graduate of an accredited Registered Nursing (RN) program
• Current California RN license required; multi-state license also required
• Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience
• Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management

Technical Skills:

• Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding
• Ability to critically evaluate claims data to inform treatment and discharge planning
• Knowledge of community resources and alternate funding programs
• Proficiency with Microsoft Office Suite
• Working knowledge of case management platforms such as Eldorado and UM Web

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off-rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $35.00-$40.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe:Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them..view all legitimate openings at personifyhealth.com/careers .