Responsibilities

• Review claims, prior auth requests, and ADT data to identify members needing case management
• Conduct clinical assessments and build individualized care plans
• Coordinate with PCPs, specialists, hospitals, and post-acute providers to ensure care execution
• Support members through complex episodes including new diagnoses and hospitalizations
• Partner with utilization management workflows on medical necessity and level of care
• Contribute to clinical protocols, escalation pathways, and internal tooling
• Maintain thorough documentation and regulatory compliance

Requirements

• Active, unrestricted RN license (multi-state compact license strongly preferred)
• 5+ years of clinical nursing experience
• Experience in case management, utilization management, care coordination, or discharge planning
• Ability to interpret claims data, prior auth criteria (MCG/InterQ...