RN Care Manager: Care Coordination & Utilization Lead

Socket.dev; Indiana (PA); On-site; USD 75,000 - 95,000; Full time

Job summary

Socket.dev is seeking a skilled nurse case manager in Pennsylvania to support patient care goals by assessing eligibility, medical necessity, and coverage for each encounter. You will coordinate care across transitions, leveraging collaboration with nursing and leadership to optimize outcomes.

The role emphasizes clear communication with physicians, payers, and hospital staff, plus ongoing patient and family education and strict adherence to discharge planning processes in a changing healthcare

Qualifications

• Diploma/associates/bachelor in nursing or health-related field
• 3-5 years medical/surgical nursing, ED experience preferred
• Case management experience in Acute, Psychiatric, or ED
• Medicare/MA/MCO and third party reimbursement
• Licensure as RN in Pennsylvania

Responsibilities

• Collaborate with nursing and case management leadership to meet organizational goals and patient care initiatives.
• Determine patient insurance eligibility, status, and benefit coverage with each patient encounter.
• Utilize medical necessity criteria to determine admission and continued stay.
• Ensure patient moves efficiently through care and resources with cost efficiency.
• Communicate with medical staff, offices, and ancillary departments regarding referrals and authorization.
• Identify issues during concurrent cases for focus and cost impact analysis.
• Analyze outcomes using data from Case Manager daily work.
• Act as liaison to pre-post hospital care providers and community health resources.

Skills

Nursing leadership

Case management

Medicare/MA/MCO reimbursement

InterQual

Milliman

Communication skills

Office suite

Education

Nursing diploma/degree

Tools

InterQual

Milliman

Job description

Socket.dev is seeking a skilled nurse case manager in Pennsylvania to support patient care goals by assessing eligibility, medical necessity, and coverage for each encounter. You will coordinate care across transitions, leveraging collaboration with nursing and leadership to optimize outcomes.

The role emphasizes clear communication with physicians, payers, and hospital staff, plus ongoing patient and family education and strict adherence to discharge planning processes in a changing healthcare