Senior Case Manager RN

• Manage a caseload of members with complex health needs requiring advanced clinical knowledge and comprehensive case management.
• Conduct detailed assessments of members’ health status, individual needs, available resources, and care requirements.
• Develop individualized and complex care plans in collaboration with members, physicians, and other healthcare providers.
• Implement and coordinate care plans to ensure members can access appropriate healthcare services, resources, and benefits.
• Monitor member progress toward established goals and adjust care plans and interventions based on changing needs.
• Evaluate the effectiveness of services and interventions to promote quality, cost-effective health outcomes.
• Advocate for members by assessing, planning, implementing, coordinating, monitoring, and evaluating available care options and services.
• Collaborate and communicate professionally with physicians, providers, colleagues, and other members of the healthcare team to support established plans of care.
• Support appropriate healthcare utilization by identifying, resolving, and preventing improper use of member benefits.
• Maintain accurate documentation and ensure activities comply with applicable processes, policies, regulatory requirements, accreditation standards, and privacy obligations.
• Provide guidance and mentorship to lower-level Case Managers and serve as a resource for clinical expertise and complex problem-solving.
• Perform additional responsibilities as assigned or requested.

Requirements:

• Bring at least 5 years of experience in a combination of clinical care, case management, utilization management, disease condition management, provider operations, and/or health insurance.
• Hold a current State RN license or current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Obtain Certified Case Manager (CCM) certification within 36 months of hire; employees already in the role as of August 2026 are exempt from this requirement.
• Have a High School diploma or GED; a Bachelor’s degree in Nursing is preferred.
• Demonstrate strong expertise in clinical assessment, care planning, healthcare systems, and case management principles.
• Bring strong leadership, mentoring, negotiation, advocacy, communication, and problem-solving skills.
• Be proficient with Microsoft Office applications, case management software, and electronic health records.
• Experience with specialty clinical areas such as Oncology, Transplant, Maternity, NICU, or Pediatrics is preferred.
• Experience supporting diverse populations and applying culturally competent approaches to targeted healthcare populations is preferred.
• Advanced training or experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT) is preferred.
• Certification in a relevant clinical specialty, such as OCN, CPN, CPON, CNN, CCTC, or CPHQ, is preferred.
• Be able to work effectively in a remote environment while meeting documentation, compliance, and care coordination requirements.
• Be available for less than 25% travel and occasional physical work-site requirements.

Benefits:

• Annual base salary ranging from $79,300 to $127,100 USD, depending on qualifications, experience, expected contributions, internal equity, market factors, and business considerations.
• Full-time remote work based in Pennsylvania, with occasional physical-site requirements.
• A role with meaningful impact on complex member care, health outcomes, care coordination, and healthcare utilization.
• Opportunities to provide clinical mentorship and contribute advanced expertise within a multidisciplinary healthcare environment.