RN Case Manager - Government Programs

Moda Health; Portland (OR); Remote; USD 72,000 - 90,000; Full time

Benefits offered by this job

Medical benefits

401K matching

FSA

Employee assistance program

PTO and holidays

Job summary

Moda Health is seeking a Registered Nurse Case Manager to perform comprehensive case management within Government Programs. This full-time, work-from-home role focuses on coordinating care for members, collaborating with providers, and ensuring timely treatment plans—all while maintaining compliance with medical policies and standards.

Ideal candidates hold an Oregon RN license, CCMC certification or willingness to obtain, and at least 3 years of relevant hospital or home health experience.

Qualifications

• Must have an accredited nursing degree and an active Oregon RN license.
• CCMC certification required or obtainable within 24 months of hire.
• Minimum 3 years of recent hospital, home health, or acute care experience.
• Proficiency with Microsoft Office; strong analytical and problem-solving skills.
• Excellent verbal and written communication; able to work under pressure.

Responsibilities

• Manage essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
• Coordinate member care plans with providers to ensure timely, appropriate care.
• Apply clinical judgment to ensure compliance with medical policy and standards of care.
• Maintain timely, accurate documentation and communicate with members and providers.
• Collaborate with other departments to resolve claims, quality of care, and provider issues.

Skills

RN license

Case management

Documentation

Communication

Time management

Education

Nursing degree

Tools

Electronic Health Records (EHR)

Job description

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary

The RN Case Manager performs case management within the boundaries of accreditation organization standards to ensure appropriate care is delivered timely and within the appropriate setting for Moda members. Interacts with the member, family, and care providers to develop, coordinate, and monitor the member’s treatment plan. This is a position within the Government Programs team. This is a FT WFH position. Salary range $71,990.85 - $89,988.57 Annually (depending on experience).

• This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Primary Functions

• Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
• Assessment: collection of in-depth information about a member’s situation and functioning to identify individual needs.
• Planning: identification of specific objectives, goals, and actions designed to meet the member’s needs as identified in the assessment.
• Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.
• Coordination: organization, securing, integrating, and modifying resources.
• Monitoring: gathering sufficient information to determine the plan’s effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
• Consults with physician advisors to ensure clinically appropriate determinations.
• Serves as a resource to internal and external customers.
• Applies clinical expertise and judgment to ensure compliance with medical policy and criteria of for accepted standards of care while performing Utilization Review and Service Authorizations for members of all books of business.
• Collaborates with other departments to resolve claims, quality of care, member, or provider issues.
• Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.
• Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
• Provides consistent, accurate and timely documentation.
• Plans, organizes, and prioritizes assignments to comply with performance standards, corporate goals, and established timelines
• Perform other duties and responsibilities as assigned.

Required Skills, Experience & Education

• Graduate of accredited school of nursing; two, three or four-year program.
• Requires current unrestricted Oregon Nursing license as a registered nurse.
• Certification in case management (CCMC) required or ability to obtain within 24 months of hire.
• Must have 3 years recent hospital, home health or acute care experience.
• Proficient with Microsoft Office applications and type a minimum of 35 wpm on a computer keyboard.
• Strong analytical, problem solving, memory retention, organizational and detail orientation skills.
• Exceptional verbal and interpersonal communication skills including management of the angry customer.
• Ability to work well under pressure.
• Project a professional business image telephonically and in person.
• Ability to come in to work on time and on daily basis.

Contact With Others & Working Conditions

• Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
• Internally with all departments and levels of staff. Externally with community organizations, state agencies, providers and office staff, healthcare associations and representatives, and members.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations please direct your questions to Kristy Nehler and Danielle Baker via our [e-mail] email.