Case Manager/RN

Kent Regency; Warwick (RI); On-site; USD 100,000 - 110,000; Full time

Benefits offered by this job

Tuition discounts

Employee Assistance Program

401K

Health, Dental, Vision insurance

Life insurance

Job summary

Kent Regency in Warwick, RI is seeking an Internal Case Manager (RN) to drive quality patient outcomes through assessment, utilization management, and discharge planning. You will collaborate with physicians, social workers, and rehab staff to align care with payor requirements and contract terms.

Applicants should have an active RN license, at least five years of clinical nursing experience, and familiarity with InterQual or Milliman criteria.

Qualifications

• Must be a graduate of an approved school of nursing with a license as a Registered Nurse or equivalent professional license.
• Bachelor’s degree in nursing preferred; CCM or related certifications are also preferred.
• Five years of recent clinical nursing experience required; prior experience in utilization review, case management or discharge planning required.
• Prior experience using evidence-based clinical decision support criteria (e.g., InterQual, Milliman).
• Advanced knowledge of third-party reimbursement, insurance coverage and contract requirements.
• Experience in rehabilitation nursing, acute care and/or the insurance field is preferred.
• Two years’ full-time experience in case management, which includes service to short/long-term facility-based residents, is preferred.

Responsibilities

• Lead assessment, utilization management, advocacy, and discharge planning to ensure appropriate care and minimize financial risk.
• Bridge care plans with payor requirements and contract terms.
• Serve as the clinical reimbursement resource for physicians, nurse practitioners, social workers, MDS coordinators, and rehab directors.
• Monitor cases for service over/under-utilization and assist with clinical appeals and notices of non-coverage.
• Identify risk factors and barriers to discharge; coordinate transitions with network providers and local staff.

Skills

Nursing license

Case management

Utilization review

Discharge planning

Interdisciplinary collaboration

Contract knowledge

Rehabilitation nursing

Education

Bachelor's degree in nursing

CCM certification

Tools

InterQual

Milliman

Job description

Overview

We are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industry, we believe in fostering a collaborative, inclusive and supportive work environment where every team member is valued and empowered to make a difference. Whether you're an experienced professional or just starting your career, we offer opportunities for growth, development, and advancement in a range of roles. Join us in our mission to enhance the well-being of our patients and residents while making a meaningful impact in the communities we serve.

Responsibilities

Are you a licensed healthcare professional skilled at bridging the gap between patient care, clinical necessity, and payor navigation? As an Internal Case Manager, you will play a central role in driving quality, cost-effective patient outcomes. You will lead the collaborative process of assessment, utilization management, advocacy, and discharge planning—ensuring every patient receives the care they need while protecting against financial risks and unreimbursed claims.

Position Highlights

• Utilization & Concurrent Review: Verify, document, and submit complete clinical data to payors from pre-admission through concurrent review (using PointClickCare and NetHealth) to justify medical necessity.
• Payor Negotiations & Authorizations: Negotiate level of care (LOC), length of stay (LOS), daily rates, and service extensions. Secure approvals for procedures, treatments, equipment, and non-formulary medications.
• Interdisciplinary Collaboration: Serve as the clinical reimbursement resource for physicians, nurse practitioners, social workers, MDS coordinators, and rehab directors to align care plans with contract terms.
• Financial Risk & Appeals Management: Monitor cases for service over/under-utilization to prevent claim denials. Assist with clinical appeals and ensure timely delivery of Notices of Non-Coverage.
• Discharge & Transition Planning: Identify risk factors, chronicity, and barriers to discharge early. Partner with network providers and local staff to ensure safe, seamless patient transitions.

Qualifications

• *Must be a graduate of an approved school of nursing with a license as a Registered Nurse or equivalent professional license (Physical Therapist, Occupational Therapist, Speech Therapist, Licensed Social Worker or Master of Social Work).
• *Bachelor’s degree in nursing preferred. Certified Case Management (CCM) or related clinical certifications are also preferred.
• *Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required.
• *Prior experience using evidence-based clinical decision support criteria (e.g.Interqual, Milliman)
• *Advanced knowledge of third-party reimbursement, insurance coverage and contract requirements.
• *Experience in rehabilitation nursing, acute care and/or the insurance field is preferred.
• *Two years’ full-time experience in case management, which includes service to short/long-term facility-based residents, is preferred.

Benefits

• *Tuition, Travel, Wireless Service, and Other Discounts
• *Employee Assistance Program to support mental health
• *Employee Foundation to financially assist through unforeseen hardships
• *Health, Dental, Vision, Company-paid life insurance, 401K, Paid Time Off
• *Free 24/7virtual health careprovided by licensed doctorsforall Anthemmedically enrolled employees and theirimmediate family members
• *On-Demand Pay Program that allows for instant access to a portion of the money you’ve already earned
• *Pet Insurance
• *Term and Whole Life Insurance
• *Short-term Disability
• *Hospital Indemnity
• *Personal Accident
• *Critical Illness
• *Cancer Coverage

Restrictions apply based on collective bargaining agreements, applicable state law and factors such as pay classification, job grade, location, and length of service.

Posted Salary Range: USD $100,000.00 - USD $110,000.00 /Yr.