Case Manager - Registered Nurse

RN Case Manager

Position Summary - This is an on-site job position in Wichita, KS

The RN Case Manager is responsible for providing comprehensive, member-centered case management services to individuals covered under employer-sponsored, self-funded health plans administered by the Third-Party Administrator (TPA).

This position focuses on identifying high-risk and high-cost members, assessing clinical and psychosocial needs, developing individualized care plans, coordinating healthcare services, and promoting appropriate, cost-effective care.

The RN Case Manager works collaboratively with members, healthcare providers, Utilization Review (UR) Nurses, Care Navigators, Pharmacy Benefit Managers (PBMs), and other healthcare partners to improve health outcomes, reduce avoidable healthcare utilization, and support members in navigating the healthcare system.

The RN Case Manager serves as a clinical advocate for members while supporting the TPA's commitment to quality care, appropriate resource utilization, and responsible management of employer health plan expenditures.

Essential Duties and Responsibilities

1. Comprehensive Member Assessment and Case Management

• Conduct comprehensive initial and ongoing assessments addressing medical conditions, medications, functional limitations, behavioral health concerns, and social determinants of health (SDOH).
  

• Identify members who may benefit from case management through utilization reports, claims data, hospital admissions, referrals, and other available clinical information.
  

• Evaluate members' understanding of their diagnoses, treatment plans, medications, and healthcare needs.
  

• Develop, implement, and regularly update individualized, measurable care plans in collaboration with members and their healthcare providers.
  

• Establish short-term and long-term goals based on identified clinical needs and member priorities.
  

• Monitor member progress, evaluate interventions, and modify care plans as necessary.
  

• Maintain an assigned caseload and prioritize interventions according to member acuity, risk, and clinical complexity.
  

2. Care Coordination and Transitions of Care

• Coordinate healthcare services across primary care providers, specialists, hospitals, rehabilitation facilities, home health agencies, and other healthcare settings.
  

• Facilitate safe and timely transitions between levels of care, including hospital discharge and post-acute care.
  

• Conduct post-discharge outreach to assess member needs, reinforce discharge instructions, and identify potential complications.
  

• Assist members with accessing appropriate providers, diagnostic services, durable medical equipment, and community resources.
  

• Identify gaps in care and facilitate interventions to reduce unnecessary emergency department visits, hospitalizations, and readmissions.
  

• Collaborate with Care Navigators to address appointment scheduling, provider access, network utilization, and nonclinical member needs.
  

3. Chronic Disease Management and Member Education

• Provide individualized education regarding chronic conditions, treatment recommendations, medications, preventive care, and lifestyle modifications.
  

• Support members managing conditions such as diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease, and other complex medical conditions.
  

• Promote adherence to recommended treatment plans and follow-up appointments.
  

• Assess member readiness to change and identify barriers affecting self-management.
  

• Utilize motivational interviewing, teach-back methods, and other evidence-based approaches to encourage member engagement.
  

• Promote preventive screenings, vaccinations, and appropriate routine healthcare services.
  

4. Medication Management and Pharmacy Collaboration

• Perform medication reconciliation and review prescribed medications for potential adherence concerns, duplication, access barriers, and affordability issues.
  

• Collaborate with Pharmacy Benefit Managers (PBMs), pharmacists, prescribers, and specialty pharmacy partners to support appropriate medication therapy.
  

• Identify opportunities for clinically appropriate, lower-cost medication alternatives in collaboration with prescribing providers and pharmacy professionals.
  

• Assist members in accessing manufacturer patient assistance programs, copay assistance, and other available medication affordability resources.
  

• Educate members regarding medication adherence, administration, potential adverse effects, and the importance of follow-up monitoring.
  

• Identify medication-related concerns requiring referral to a pharmacist or prescribing provider.
  

• Coordinate with PBMs and pharmacy partners regarding specialty medications, formulary requirements, and medication access issues.
  

5. Utilization Review and Cost-Containment Collaboration

• Collaborate with UR Nurses and the Medical Director to identify members requiring additional clinical support.
  

• Review available claims, utilization, and clinical information to identify potentially avoidable healthcare expenditures.
  

• Identify opportunities to guide members toward appropriate, high-quality, cost-effective healthcare services.
  

• Coordinate with Care Navigators regarding in-network providers, preferred facilities, and available cost-saving programs.
  

• Support appropriate utilization of healthcare resources while maintaining member safety and clinical quality.
  

• Identify high-cost treatment episodes and complex care needs requiring proactive case management intervention.
  

• Assist in coordinating alternative treatment settings when clinically appropriate and consistent with plan benefits.
  

• Refer coverage or medical necessity questions to the appropriate UR or benefits administration personnel.
  

6. Member Advocacy and Resource Coordination

• Serve as a primary clinical resource for members enrolled in case management.
  

• Establish therapeutic relationships through compassionate, professional, and culturally responsive communication.
  

• Identify barriers related to transportation, housing, food insecurity, financial limitations, health literacy, and access to healthcare.
  

• Connect members with appropriate community resources and support services.
  

• Facilitate communication among members, caregivers, providers, and other healthcare professionals.
  

• Respect member autonomy, confidentiality, and informed decision-making.
  

• Escalate urgent clinical concerns and safety issues according to established protocols.
  

7. Documentation, Reporting, and Regulatory Compliance

• Maintain complete, accurate, and timely documentation of assessments, care plans, member interactions, interventions, and outcomes.
  

• Document case management activities in the designated electronic case management system.
  

• Maintain compliance with HIPAA, applicable ERISA requirements, state and federal regulations, and organizational policies.
  

• Follow established confidentiality, information security, and professional nursing standards.
  

• Participate in internal audits, quality improvement initiatives, and case reviews.
  

• Identify and report potential quality-of-care concerns, patient safety issues, and compliance risks.
  

• Maintain appropriate documentation supporting case management outcomes and program effectiveness.
  

8. Interdisciplinary Collaboration and Operational Responsibilities

• Participate in interdisciplinary case conferences and clinical team meetings.
  

• Collaborate with RN Utilization Review Nurses, Care Navigators, the Medical Director, and department leadership.
  

• Communicate significant member concerns, high-risk situations, and barriers to care to appropriate team members.
  

• Participate in daily huddles, departmental meetings, and performance improvement initiatives.
  

• Assist with development and refinement of case management workflows, educational resources, and clinical protocols.
  

• Maintain productivity and performance expectations established by department leadership.
  

• Perform other duties as assigned within the scope of professional nursing practice.
  

Requirements

Benefits

Compensation and Benefits

Unified Health Plan offers a competitive compensation and benefits package designed to support the health, financial well-being, and work-life balance of our employees.

Our benefits package may include:

• Competitive salary based on qualifications and experience
  

• Comprehensive medical, dental, and vision insurance
  

• Company-sponsored life insurance
  

• Short-term and long-term disability coverage
  

• 401(k) retirement savings plan with employer matching
  

• Paid time off (PTO)
  

• Paid company holidays
  

• Supportive, team-oriented work environment
  

• Consistent Monday–Friday work schedule