Senior Case Manager, RN

Jobtailor; Pennsylvania; On-site; USD 70,000 - 90,000; Full time

Job summary

Jobtailor is seeking a qualified RN Case Manager in Pennsylvania to oversee a caseload of members with complex health needs. You will assess health status, develop detailed care plans, and coordinate with physicians and care teams to ensure access to appropriate services.

The role requires an RN license (or multi-state eNLC) and CCM certification within 36 months. Strong leadership, advocacy, and a solid grasp of healthcare systems are essential.

Qualifications

• 5 years in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience
• High School/GED is required
• Current State RN licensure or multi-state licensure via eNLC is required
• CCM certification must be obtained within 36 months of hire; existing holders exempt until Aug 2026
• Expertise in clinical assessment and care planning
• Strong leadership and mentoring skills
• Excellent negotiation and advocacy skills
• Proficiency in Microsoft suite, case management software, and electronic health records
• Strong understanding of healthcare systems and case management principles
• Ability to work with physicians, providers, co-workers, and healthcare team members
• Compliance with HIPAA, privacy, information security, and code of business conduct requirements

Responsibilities

• Manage a caseload of members with complex health needs
• Conduct comprehensive assessments and develop complex care plans
• Assess members’ health status, needs, and available resources
• Develop individualized care plans with members, physicians, and healthcare providers
• Implement and coordinate care plans and access to services
• Monitor member progress and adjust care plans as needed
• Evaluate the effectiveness of interventions and services
• Advocate and act as a liaison to meet members’ healthcare needs
• Promote quality, cost-effective outcomes in accordance with contract benefits
• Detect, resolve, and prevent improper utilization of member benefits
• Collaborate with physicians, providers, co-workers, and healthcare team members
• Document activities in compliance with requirements
• Provide guidance and mentorship to lower-level Case Managers
• Serve as a resource for clinical expertise and problem-solving
• Perform other duties as assigned

Skills

Clinical Assessment

Care Planning

Case Management Principles

Utilization Management

Disease Condition Management

Education

High School/GED

Current State RN Licensure

Certified Case Manager (CCM)

Tools

Microsoft Suite

Case Management Software

Electronic Health Records

Job description

• Manage a caseload of members with complex health needs
• Conduct comprehensive assessments and develop complex care plans
• Assess members’ health status, needs, and available resources
• Develop individualized care plans with members, physicians, and healthcare providers
• Implement and coordinate care plans and access to appropriate services and resources
• Monitor member progress and adjust care plans as needed
• Evaluate the effectiveness of interventions and services
• Advocate and act as a liaison to meet members’ individual healthcare needs
• Promote quality, cost-effective outcomes in accordance with contract benefits
• Detect, resolve, and prevent improper utilization of member benefits
• Collaborate and communicate with physicians, providers, co-workers, and healthcare team members
• Document activities in compliance with business, company, regulatory, and accreditation requirements
• Provide guidance and mentorship to lower-level Case Managers
• Serve as a resource for clinical expertise and problem-solving
• Perform other duties as assigned or requested

Requirements

• 5 years in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience
• High School/GED
• Current State RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Certified Case Manager (CCM) certification must be obtained within 36 months of hire; incumbents in the role as of August 2026 are exempt
• Expertise in clinical assessment and care planning
• Strong leadership and mentoring skills
• Excellent negotiation and advocacy skills
• Proficiency in Microsoft suite of applications, case management software, and electronic health records
• Strong understanding of healthcare systems and case management principles
• Ability to work with physicians, providers, co-workers, and other healthcare team members
• Compliance with applicable business process requirements, company policies, regulatory requirements, accreditation standards, HIPAA, privacy, information security, and code of business conduct requirements

Core Competencies

Demonstrates expertise in clinical assessment, care planning, and case management principles while effectively collaborating with healthcare teams to advocate for members' healthcare needs. Proficient in compliance with regulatory requirements and skilled in mentoring and leadership within a clinical setting.

Highest-signal resume keywords

• Clinical Assessment
• Care Planning
• Certified Case Manager (CCM)
• Leadership and Mentoring
• Healthcare Systems Knowledge

Hard Skills

• Clinical Assessment
• Care Planning
• Case Management Principles
• Utilization Management
• Disease Condition Management

Soft Skills

• Negotiation Skills
• Advocacy Skills
• Collaboration Skills

Certifications & Qualifications

• Current State RN Licensure
• Certified Case Manager (CCM)

Industry Keywords

• Healthcare
• Regulatory Compliance
• Accreditation Standards
• HIPAA
• Information Security

Tools & Technologies

• Microsoft Suite
• Case Management Software
• Electronic Health Records