Registered Nurse Case Manager

Proforma Health; Philadelphia (Philadelphia County); On-site; USD 75,000 - 98,000; Full time

Job summary

Proforma Health is seeking a Nurse Reviewer to assess medical cases for service appropriateness according to clinical guidelines and member benefits. You will partner with providers and care management teams to support quality care decisions and ensure proper utilization.

The role requires strong clinical judgment, clear communication, and meticulous case analysis. Based in Philadelphia, this on-site position offers opportunities to impact discharge planning and referrals within our

Qualifications

• Active PA RN license or NLC license required.
• Strong ability to interpret clinical guidelines and benefit information.
• Excellent communication and coordination with providers and internal teams.

Responsibilities

• Assess case details to verify requested services align with established clinical guidelines and benefit criteria.
• Coordinate with providers and care management staff to support appropriate care decisions.
• Identify discharge planning needs and facilitate referrals as appropriate.
• Refer cases for quality review and/or additional case management when indicated.

Skills

Clinical judgment

Guideline interpretation

Communication & coordination

Education

Registered Nurse license (PA) or NLC

Job description

Role Overview

Review medical cases to determine the appropriateness of requested services by applying clinical guidelines and member benefit information.

Key Responsibilities

• Assess case details to verify requested services align with established clinical guidelines and benefit criteria.
• Coordinate with providers and care management staff to support appropriate care decisions.
• Identify discharge planning needs and facilitate referrals as appropriate.
• Refer cases for quality review and/or additional case management when indicated.

Qualifications & Skills

• Active Pennsylvania RN license or a qualifying Nurse Licensure Compact (NLC) license.
• Strong clinical judgment and ability to interpret guidelines and benefit information.
• Excellent communication and coordination skills with providers and internal teams.
• Detail-oriented case analysis with a focus on quality and appropriate service utilization.