Hybrid Care Manager RN | High-Risk Member Support

Peak Health; Core (WV); Hybrid; USD 65,000 - 90,000; Full time

Job summary

PHH Peak Health Holdings in Morgantown, WV is seeking a Care Manager to join the health plan’s medical management team. The role focuses on identifying high-risk members and connecting them with resources and in-network providers to improve outcomes.

The position requires RN licensure, three years of healthcare clinical experience, and knowledge of NCQA standards for care management. This hybrid, on-site role supports program build, utilization reviews, member outreach, and collaboration with

Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years of healthcare clinical experience.

Responsibilities

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding their available medical benefits and connecting them with in network providers and community resources.
• Identify barriers preventing the member from meeting maximum quality of life.
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigating potential quality of care issues that may affect the quality or safety of the health of members.
• May review medical records and other documentation to ensure quality care.
• Assist in reviewing and updating activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in reviewing and updating policies and procedures to align with delegated processes.
• Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assist in submission of required documents/policies during application process to accrediting body.

Skills

InterQual & Milliman care guidelines

Excellent written & oral communication

Problem solving

Attention to detail

Microsoft Office

Education

RN license (state or eNLC)

BSN or ASN preferred; BSN completion within 3 years

Tools

InterQual

Milliman Care Guidelines

Job description

PHH Peak Health Holdings in Morgantown, WV is seeking a Care Manager to join the health plan’s medical management team. The role focuses on identifying high-risk members and connecting them with resources and in-network providers to improve outcomes.

The position requires RN licensure, three years of healthcare clinical experience, and knowledge of NCQA standards for care management. This hybrid, on-site role supports program build, utilization reviews, member outreach, and collaboration with