Chronic Disease Case Manger Nurse-RN

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

KEY COMPETENCIES: To be successful in a remote healthcare environment, individuals must demonstrate strong technical aptitude, communication skills, and the ability to work independently. Upon Hire, must have: 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, but not limited to, Microsoft Word, Microsoft Excel, and Microsoft Outlook Strong verbal and written communication skills, including the ability to clearly explain complex or technical information and accurately interpret information received from others. Ability to work independently, manage time effectively, utilize written resources to problem-solve and make informed decisions. Foundational knowledge of medical claims processing and medical terminology, including ICD10, CPT, and HCPCS coding. Post‑Training Expectations: After completion of initial training and a structured ramp period (approximately three [3] months total), demonstrate proficiency in required systems and tools, including but not limited to: Microsoft Teams (on- and off-camera), SharePoint, shared drives, VPN UM Web, Health Notes, MyCare, ADP, Confluence Phone system with headset Ability to quickly adapt to additional systems or tools as job responsibilities evolve.

Telephonically coordinate wellness and disease management for members with chronic conditions, including but not limited to 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 and comparing current care with industry standards. Review gaps in care and medical and pharmacy paid claims data to develop a comprehensive clinical profile; create individualized care plans and provide close follow-up for actively managed patients. Collaborate with members to ensure assignment to a primary care provider; facilitate referrals to specialists as needed; assist with obtaining durable medical equipment and reviewing pricing for high-cost medications. 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 as appropriate. Maintain complete, accurate, and timely documentation of case-managed members in designated systems; document all interventions and patient contacts while ensuring confidentiality and privacy of member records. Track and monitor moderate and high-risk member populations and associated interventions to demonstrate improvements in overall health outcomes. Meet established productivity, quality, and turnaround time standards on a daily, weekly, monthly basis. Successfully participate in and pass external audits, including NCQA and URAC. Maintain HIPAA compliance and confidentiality requirements in accordance with company policies and procedures. Complete all required annual training within designated timeframes.