Chronic Disease Case Manager Nurse (RN)

1w1 week ago

Personify Health

US · Full-time · $62,000 – $76,000

About this role

Personify Health created the first personalized health platform, uniting health plan administration, holistic wellbeing solutions, and comprehensive care navigation. We serve employers, health plans, and health systems with data-driven solutions that reduce costs and improve health outcomes. Our team empowers people to lead healthier lives.

As a Chronic Disease Case Manager Nurse, telephonically coordinate wellness and disease management for members with conditions like diabetes, asthma, COPD, CAD, CHF, hypertension, and hyperlipidemia. Proactively contact targeted members, apply national care guidelines, and compare current care to industry standards. Develop comprehensive clinical profiles and individualized care plans from gaps in care and claims data.

Work remotely in a healthcare environment requiring strong technical aptitude, communication skills, and independent operation. Collaborate with members on primary care providers, specialist referrals, durable medical equipment, and high-cost medications. Support utilization review, assess needs for program referrals, and maintain accurate documentation while ensuring confidentiality.

Track moderate and high-risk members to demonstrate health outcome improvements and meet productivity, quality, and turnaround standards. Participate in external audits like NCQA and URAC, maintain HIPAA compliance, and complete required annual training. Contribute to restoring optimal functioning through close follow-up and interventions.

Requirements

Registered Nurse (RN) license
Basic computer literacy with the ability to navigate multiple systems simultaneously
Ability to work on multiple screens with proficient typing skills
Proficiency in software applications including Microsoft Word, Microsoft Excel, and Microsoft Outlook
Strong verbal and written communication skills to explain complex information
Ability to work independently, manage time effectively, and problem-solve using written resources
Foundational knowledge of medical claims processing and medical terminology, including ICD10, CPT, and HCPCS coding

Responsibilities

Telephonically coordinate wellness and disease management for members with chronic conditions, including diabetes, asthma, COPD, CAD, CHF, atrial fibrillation, hypertension, and hyperlipidemia
Proactively contact targeted members to promote health and restore optimal functioning by applying nationally recognized care guidelines
Review gaps in care and medical and pharmacy paid claims data to develop comprehensive clinical profiles and individualized care plans
Collaborate with members to ensure assignment to a primary care provider and facilitate referrals to specialists as needed
Support the Utilization Review process for assigned members in accordance with organizational and regulatory standards
Assess member needs and initiate referrals to case management, prenatal, wellness programs, and external vendor services
Maintain complete, accurate, and timely documentation of case-managed members in designated systems
Track and monitor moderate and high-risk member populations and interventions to demonstrate improvements in health outcomes