Ready to be the difference between a confusing diagnosis and a clear path forward?

Why This Role Matters

When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale.

What You'll Actually Do

• Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture.
• Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs.
• Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals.
• Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working.
• Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care.
• Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses.
• Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports.
• Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines.
• Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate.
• Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA.
• Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making.