RN Care Manager for LTC Claims & Care Plans

Wellcove CHCS Services; United States; A distancia; USD 70.000 - 95.000; Jornada completa

Descripción de la vacante

Wellcove CHCS Services is seeking an experienced Registered Nurse (RN) to serve as a Care Manager supporting Long Term Care insurance claims. You will perform detailed clinical reviews to determine eligibility and assess ADLs, cognition, and care needs.

You will review medical records, MDS assessments, and claim documents, determine Chronically Ill status, and prepare CICs and Plans of Care for approvals and recertifications.

Formación

• Clinical experience in long-term care, home health, geriatrics, case management, or utilization review.
• Strong clinical judgement and documentation skills.
• Ability to manage multiple cases and meet turnaround expectations.

Responsabilidades

• Perform detailed clinical reviews of LTC claim files to determine eligibility in accordance with policy provisions and regulatory requirements.
• Assess Activities of Daily Living (ADLs), cognitive impairment, diagnoses, comorbidities, and level of care needs.
• Review medical records, Minimum Data Set (MDS) assessments, facility documentation, home health records, daily visit notes, and supporting claim forms.
• Determine whether the insured meets the policy definition of Chronically Ill.
• Prepare and document Chronically Ill Certifications (CICs) and individualized Plans of Care (POCs) for initial approvals and recertifications.
• Clearly document clinical rationale to support benefit determinations.

Conocimientos

Geriatrics

Case management

Medical record review

Educación

RN license

Descripción del empleo

Wellcove CHCS Services is seeking an experienced Registered Nurse (RN) to serve as a Care Manager supporting Long Term Care insurance claims. You will perform detailed clinical reviews to determine eligibility and assess ADLs, cognition, and care needs.

You will review medical records, MDS assessments, and claim documents, determine Chronically Ill status, and prepare CICs and Plans of Care for approvals and recertifications.