Remote Nursing Jobs • Case Management

The Utilization Management Nurse is responsible for managing requests providing a multi-faceted approach to managing requests for medical services while ensuring the services are medically appropriate and necessary. This role requires a multi-faceted approach, utilizing evidence-based clinical guidelines and input from healthcare providers to achieve high-quality, cost-efficient medical outcomes for patients.

Support a high-need Medicaid population through proactive, whole-person care as a Bilingual RN Care Manager. The role involves delivering integrated medical, behavioral, and social support to individuals with complex needs and serving as the primary point of contact for a panel of high-risk members, contributing clinical expertise to build trust, address health disparities, and coordinate care across settings.

Medically manage assigned caseload and, by applying clinical expertise, ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost-effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners.

This role plays a key part in Welby Health's remote physiological monitoring (RPM) program by providing ongoing clinical oversight, developing patient care plans, and offering support and education to help patients improve their health outcomes. The position requires clinical guidance, patient education, and care coordination with physicians.

Provide clinically-based case management to support the delivery of effective and efficient patient care by integrating utilization management, care coordination, and transition planning functions. Manages a designated case load and plans effectively in order to meet patients needs, manage the length of stay, and promote efficient utilization of resources. Supports the physician in facilitating patient care with the objective of enhancing the quality of patient outcomes and patient satisfaction.

The UM Nurse Specialist conducts clinical reviews to ensure that services provided to members meet clinical criteria and are delivered in appropriate settings, coordinating all aspects of utilization and benefit management. They validate medical documentation, consult with medical directors, and identify members for case management, also conducting retrospective medical claims audits.

Works with Aledade primary care practices in Maryland as a part of the Maryland Primary Care Program. The care manager collaborates with the care team within each practice and leverages Aledade’s interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. The care manager works closely with Medicare patients to support them in becoming active in their health care.