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Case Manager Nurse- RN
2026-4519 Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. As a Case Manager Nurse RN, you will provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. May be required to work evening and/or weekend shifts.
Responsibilities
Ready to What You'll Actually Do Essential Functions/Responsibilities/Duties- Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
- Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs.
- Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
- Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions.
- Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care.
- Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
- Be able to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis.
- Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports.
- Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance and information.
- Evaluate and make referrals for wellness programs.
- Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90 days interval for low-risk cases ensuring confidentiality according to Company policy and HIPAA
- Perform Utilization Review for assigned members.
- Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issues.
Qualifications
What You Bring to Our Team Education and Experience- Graduation from an accredited Registered Nursing (RN) program.
- Possession of a current California RN license; a multi-state license will also be required.
- Minimum of five (5) years medical/surgical or acute care experience, including two years’ experience in case management, or an equivalent combination of education and experience.
- Prior case management experience, emergency room, critical care background or other relevant clinical care experience pertinent to case management.
- Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
- Ability to critically evaluate claims data and determine treatment plan, discharge planning experience.
- Ability to work independently making decisions and problem solving
- Knowledge of community resources and alternate funding programs.
- Computer proficiency or working knowledge of Microsoft Office Suite.
- Excellent interpersonal, communication and negotiation skills.
- Strong customer orientation.
- Good time management skills and highly organized.
- Must be able to remain in a stationary position 50% of the time.
- The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities.
- Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
- Frequently positions self to maintain files in file cabinets.
- Frequently moves boxes or equipment weighing up to 25 pounds.
- Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations.
- Must be able to observe details at close range.
- Competitive base salary and benefits effective day one
- Comprehensive medical and dental through our own health solutions (yes, we use what we build)
- Paid Time Off—rest and recharge time is non-negotiable
- Mental health support, retirement planning, and financial protection
- Professional development with clear career progression and learning budgets
- Mission-driven culture where diverse perspectives drive real impact on people's health
