Job: Case Manager - RN or LPN

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Job Description

Case Manager - RN or LPN


Job-Nursing - LPN
Daily Schedule-Days
Scheduled Hours per 2-week Pay Period-80
Weekends Required -None


It is the responsibility of the Case Manager to facilitate coordination, communication, and collaboration with members, providers, ancillary service providers, and others in order to achieve goals and maximize positive member outcomes based upon an individual assessment of each member’s needs. The Case Manager facilitates referrals, authorizations, discharge planning and s/he works collaboratively with other departments to enhance the quality of patient experience and satisfaction, while promoting continuity of care and cost-effectiveness.



Essential Duties and Responsibilities

  • Assess and provide case management for members with complex conditions per established criteria. 

  • Implement population identification processes when appropriate;

  • Use a Member-centered, strengths-based, collaborative, holistic partnership approach;

  • Promote Member self-determination through advocacy;

  • Practice cultural competence, with awareness and respect for diversity;

  • Implement Care Plans that include Member and/or Member representative, physician and ancillary providers;

  • Facilitate informed choice, consent, and decision-making;

  • Promote the Member’s self-care management;

  • Facilitate Member self-advocacy, education, and guidance;

  • Promote the use of evidence-based care, as available;

  • Promote optimal Member safety;

  • Link Members with community resources as appropriate;

  • Assist Members with navigating the health care system to promote effective transitional care

  • Use process and outcome measurement, evaluation, and management tools to improve quality performance.

  • Follows strict adherence to departmental standards of confidentiality of medical and proprietary information. 

  • Pursue professional excellence and maintain competence in practice

  • Performs Utilization Management of Members open to Case Management as requested

  • Performs other duties as assigned.


Education and Experience

  • At least 2 years health plan (or similar) experience doing utilization management and/or Case Management

  • Degree from an accredited school of nursing -BSN preferred

  • Current unrestricted RN license for the State of Washington and other states if indicated

  • Minimum three years of clinical experience

  • Demonstrated competency with Microsoft Office Suite

  • Case Management Certification preferred

  • Experience working with Medicare Advantage/Centers for Medicare and Medicaid Services

Knowledge, Skills and Abilities

  • Varied Knowledge of clinical areas of medical treatment impacting the senior population.

  • Knowledge of Interqual or Milliman Utilization Criteria

  • Knowledge of hospital/patient care facilities, current practices, procedures, acceptable medical treatment and diagnoses.

  • Ability to learn and execute company policies and procedures as they relate to authorizations/denials, facility concurrent review, case management, appeals, etc.

  • Strong verbal and written communication to ensure the accurate transferability of information and to build rapport that will ensure the trust, confidence and cooperation of others in a work situation.

  • Excellent record-keeping skills necessary to provide complete information and documentation for relevant and appropriate medical determinations.

  • Ability to establish and maintain effective work relationships.

  • Ability to effectively respond to pharmacy and related formulary questions.

  • Exemplary telephone comportment with a wide range of contacts including members and providers from various cultures and levels of education.

  • Exceptional organizational skills

  • Excellent computer skills and the ability to use multiple software/Microsoft Office Suite programs interchangeably during the execution of daily duties

  • Analytic skills to collect, monitor, and evaluate data.

  • Keen understanding of the medical and social needs of the senior population.

  • Understanding of the role of palliative and hospice care.

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.  

Requisition Title

QualChoice Health