Mphc Case Jobs in Usa
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Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.
Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.
Provides support for claim appeals in relation to medical necessity.
Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.
Facilitates member second level appeal process.
Graduate from an accredited school of professional nursing is required.
BSN preferred.
Minimum 2 years acute care experience or managed care experience is required.
Basic knowledge of Medicaid, Medicare preferred.
Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.
Active Certification in Case Management (CCM) is preferred.
Nurse Case Manager
$72,000/year + $3,000 Sign-On Bonus Hybrid Work Options Flexible Scheduling Low Individuals-to Staff Ratios Mileage Reimbursement
Balance Your Career and Life While Making a Real Impact
Join Sevita as a Nursing Case Manager and experience the difference of working in a role that values your expertise and supports your well-being. Enjoy a hybrid work environment, smaller caseloads, and flexible scheduling designed to help you deliver compassionate, high-quality care without burnout.
Why This Role Stands Out
- Competitive salary of $72,000/year plus a $3,000 sign-on bonus.
- Hybrid work options that balance fieldwork with remote flexibility.
- Flexible schedules-no 12-hour shifts or mandatory rotating weekends/holidays.
- Mileage reimbursement for travel to support individuals in the community.
- Smaller caseloads than typical hospitals or nursing homes, giving you more time to build meaningful relationships and deliver personalized care.
- A mission-driven, nurse-first culture that prioritizes your growth and work-life balance.
I appreciate the ability to create my own schedule, with no 12-hour shifts and rotating weekends and holidays. I also find peace in knowing that if my schedule has to change because of my kids' schedules or doctors' appointments, I have the flexibility to rearrange my schedule without being penalized or being responsible to find someone to cover my shift. - LaKita, Health Services Manager
What You'll Do
- Perform intake assessments for individuals served, including submission of required documentation for prior authorization of services as needed based on pay sources
- Develop care plans based on nursing diagnoses and physician input, including medical interventions and measurable goals or outcomes
- Routinely review medical data to evaluate service effectiveness and rehabilitation potential
- Investigate and resolve individual or employee concerns/complaints
- Ensure aides are properly oriented and trained to meet individual needs in line with policies and procedures
- Perform periodic supervisory visits and instruct individuals, families, and caregivers as needed
- Ensure coordination of home care services through timely completion of documentation and medical data transfer
- Provide input on agency policies, procedures, and practices
- Participate in advisory boards or agency committees as requested
- Nursing degree with a valid Missouri RN license
- At least 2 years of relevant nursing experience
- Strong communication and analytical skills
- Ability to multitask while staying detail-oriented
- Self-motivation and a passion for our mission
- $3,000 Sign-On Bonus ($1,500 at 30 days, $1,500 at 90 days).
- Comprehensive medical, dental, and vision coverage.
- Paid time off and holiday pay.
- 401(k) with company match.
- On-Demand Pay-access your earnings when you need them.
- Leadership training and career advancement opportunities.
Join Sevita and discover how rewarding nursing can be when you're truly supported and empowered. Apply today and start making a lasting difference in your community.
Sevita is a leading provider of home and community-based specialized health care. We believe that everyone deserves to live a full, more independent life. We provide people with quality services and individualized supports that lead to growth and independence, regardless of the physical, intellectual, or behavioral challenges they face.
We've made this our mission for more than 50 years. And today, our 40,000 team members continue to innovate and enhance care for the 50,000 individuals we serve all over the U.S.
As an equal opportunity employer, we do not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, citizenship, or any other characteristic protected by law.
Job Summary As one of the Top 8 Most Innovative Healthcare Systems in Becker's Hospital Review, we're working to create a national model for improving health.
Today, we're focused on bringing our region services that improve every facet of life to drive total health, inside and out.
Through professional growth, quality improvement, and interdisciplinary collaboration, we've built an innovative culture that allows nurses to grow their skillsets, develop their practice, and leverage their years of experience to build a rewarding, lasting career with impact.
Job Duties This role is per diem.
Hours are typically 8am-4:30 PM.
At least two (2) years of prior RN experience is required.
Pediatric and/or Obstetrics experience is preferred.
Position Details The Registered Nurse Case Manager assesses, plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient or member's health status.
Manages utilization and practice metrics to further refine the delivery of care model to maximize clinical, quality, and fiscal outcomes.
Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the identified population.
Develops systems of care that monitor progress and promote early intervention in acute care situations.
Assists with the design, implementation, and evaluation of the advanced patient centered care model.
Assesses the healthcare, educational and psychosocial needs of patients or members.
Designs an individualized plan of care and fosters a team approach by working collaboratively with the patient or member, family, primary care provider, and other members of the health care team to ensure coordination of services.
Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population.
Works to appropriately apply benefits and utilization management serving as a resource to the patient or member and healthcare team.
Maintains required documentation for all case management activities.
Collects required data and utilizes this data to adjust the treatment plan when indicated.
Work is typically performed in a clinical environment.
Accountable for satisfying all job specific obligations and complying with all organization policies and procedures.
The specific statements in this profile are not intended to be all-inclusive.
They represent typical elements considered necessary to successfully perform the job.
Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Education Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Nursing (Preferred) About Geisinger OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.
KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
EXCELLENCE: We treasure colleagues who humbly strive for excellence.
LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality.
We know that a diverse workforce with unique experiences and backgrounds makes our team stronger.
Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all.
We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.
We are committed to empowering those we serve to live as independently as possible, be included in their communities, and reach their full potential.
This mission extends to our employees, who bring our mission to life each day.
We actively strive to be a workplace that honors the unique experiences, perspectives, and strengths of our employees.
We believe we are stronger, better, and more effective in our pursuits when we create space for everyone to be their authentic selves.
Benchmark Human Services has grown to become one of the most respected leaders in the country in the areas of intellectual and developmental disabilities (IDD) and behavioral health.
We work with people of all ages at home, at work, and in the community through residential programs, employment services, crisis response, early intervention, and more.
View our 65 Years of Stories campaign to learn more about the impact Benchmark employees have made across the country.
Benchmark is looking for a Case Manager to work in the Southeast Region of SD.
Position is remote -- candidates must live in South Dakota.
GENERAL RESPONSIBILITIES Provide resources and support to individuals with intellectual and developmental disabilities, their families and guardians in order for the individual to be included in society, live as independently as possible and function at their maximum potential.
The focus of the position is to provide services to individuals with intellectual disabilities with the goal of linking individuals and their families to resources to ensure the individuals overall health, safety and well-being.
BENEFITS Health, vision and dental insurance Life Insurance 401k plan with company match Profit sharing Tuition Reimbursement Paid Time Off and Sick Time Pay Flexible Spending Accounts (FSA) Advancement Opportunities ESSENTIAL FUNCTIONS AND RESPONSIBILITIES Follow all policies and procedures set forth by the company, South Dakota Department of Human Services, Division of Developmental Disabilities, Home and Community Based Services (HCBS) rules.
Perform evaluations and assessments to meet the needs of individuals served.
Assist individuals served with applying for financial assistance, residential planning, vocational, recreational and educational desires, healthcare, in home supports, day services, legal, nutrition, transportation, social, and other related services and resources.
Advocate for services that will support the individual’s success.
Maintain all case records.
Prepare, update and monitor person centered plans including utilization of discovery through Charting the Life Course and Person-Centered Thinking (PCT) Tools.
Provide support to individuals so they can participate in and direct the person-centered plan development process.
Coordinate meetings with individual, families and guardians, and members of the interdisciplinary team as required.
Establish and maintain positive relationships with individual, families, guardians, state officials and team members.
Record work and billing time in accordance with company policies.
Track, monitor and enter specified data points.
Report any suspected abuse, neglect or exploitation immediately to supervisor or department head.
Comply with all standards to assure the health and safety of all individuals.
QUALIFICATION A degree in the human services field is preferred or a minimum of 2 years working in health or human services.
The candidate must have a valid driver's license and maintain auto insurance.
The candidate must demonstrate excellent communication skills.
Candidates must live in South Dakota Interested candidates can apply online at /Careers Benchmark Human Services is an EOE/AAP Employer.
Veterans, women, and individuals with disabilities are encouraged to apply.
Candidates selected for hire will be required to complete a background check in accordance with company policy and applicable laws.
INDMGR
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making. Provides support for claim appeals in relation to medical necessity. Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards. Facilitates member second level appeal process.
EDUCATION/EXPERIENCE
Graduate from an accredited school of professional nursing is required. BSN preferred. Minimum 2 years acute care experience or managed care experience is required. Basic knowledge of Medicaid, Medicare preferred. Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
LICENSURE
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making. Provides support for claim appeals in relation to medical necessity. Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards. Facilitates member second level appeal process.
EDUCATION/EXPERIENCE
Graduate from an accredited school of professional nursing is required. BSN preferred. Minimum 2 years acute care experience or managed care experience is required. Basic knowledge of Medicaid, Medicare preferred. Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
LICENSURE
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.
Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.
Provides support for claim appeals in relation to medical necessity.
Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.
Facilitates member second level appeal process.
Graduate from an accredited school of professional nursing is required.
BSN preferred.
Minimum 2 years acute care experience or managed care experience is required.
Basic knowledge of Medicaid, Medicare preferred.
Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.
Active Certification in Case Management (CCM) is preferred.
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity.
Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making.
Provides support for claim appeals in relation to medical necessity.
Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards.
Facilitates member second level appeal process.
Graduate from an accredited school of professional nursing is required.
BSN preferred.
Minimum 2 years acute care experience or managed care experience is required.
Basic knowledge of Medicaid, Medicare preferred.
Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required.
Active Certification in Case Management (CCM) is preferred.
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making. Provides support for claim appeals in relation to medical necessity. Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards. Facilitates member second level appeal process.
EDUCATION/EXPERIENCE
Graduate from an accredited school of professional nursing is required. BSN preferred. Minimum 2 years acute care experience or managed care experience is required. Basic knowledge of Medicaid, Medicare preferred. Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
LICENSURE
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.
Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making. Provides support for claim appeals in relation to medical necessity. Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards. Facilitates member second level appeal process.
EDUCATION/EXPERIENCE
Graduate from an accredited school of professional nursing is required. BSN preferred. Minimum 2 years acute care experience or managed care experience is required. Basic knowledge of Medicaid, Medicare preferred. Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
LICENSURE
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.
Remote working/work at home options are available for this role.
