RN Care Manager: Long-Term Care Claims

Wellcove; Pensacola (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

Wellcove seeks an experienced Registered Nurse (RN) to act as a Care Manager supporting Long Term Care insurance claims in Pensacola. This individual contributor role conducts comprehensive clinical eligibility reviews and documents Chronically Ill Certifications and Plans of Care for initial and recertification activities.

The RN will collaborate with Claims, Eligibility, and Customer Service teams, review MDS assessments and medical records, and stay current on LTC policy language and

Qualifications

• Active, unrestricted RN license.
• Experience in long-term care, home health, geriatrics, case management or utilization review.
• Experience reviewing medical records and assessing functional and cognitive impairment.
• Knowledge of LTC policy language, benefit triggers, and chronically ill certification standards.
• Strong clinical judgment, critical thinking, and documentation skills.

Responsibilities

• Perform detailed clinical reviews of LTC claim files to determine eligibility.
• Assess ADLs, cognitive impairment, diagnoses, comorbidities, and level of care needs.
• Review medical records, MDS assessments, facility documentation, home health records, daily notes, and claim forms.
• Determine whether the insured meets the policy definition of Chronically Ill.
• Prepare and document Chronically Ill Certifications (CICs) and Plans of Care (POCs).
• Document clinical rationale to support benefit determinations.
• Collaborate with Claims, Eligibility, and Customer Service teams to obtain documentation.
• Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

Skills

RN license

Geriatrics

Case management

Utilization review

Documentation

ADL assessment

MDS knowledge

Education

Bachelor of Science in Nursing (BSN)

Tools

EHR systems

Job description

Wellcove seeks an experienced Registered Nurse (RN) to act as a Care Manager supporting Long Term Care insurance claims in Pensacola. This individual contributor role conducts comprehensive clinical eligibility reviews and documents Chronically Ill Certifications and Plans of Care for initial and recertification activities.

The RN will collaborate with Claims, Eligibility, and Customer Service teams, review MDS assessments and medical records, and stay current on LTC policy language and