Case Manager, RN

About the role

The RN is responsible for providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience. Position Location: 100% Remote. Position Start Date: 9/21/26.

Responsibilities

• Identify, collect, process and manage data to perform the Case Management process by utilizing Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures
• Completes clinical assessments per P&P to identify and deliver indicated medical service coordination
• Completes medical necessity, utilization management reviews, and review of benefits as part of the pre-determination process
• Identify and refer cases for Physician Advisor reviews
• Utilize clinical knowledge, expertise and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment
• Assess the need for and collaborate with community resources for members in case management
• Perform negotiations with providers
• Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips
• Facilitate the Patient Satisfaction Surveys
• Assess for cost savings and document the cost saving in assigned software platform
• Appropriately refer complex cases to Manager, Case Management
• Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite
• Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and Medical Management Policy and Procedure
• Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy

Required Experience & Education

• Nursing degree from an accredited college, university, or nursing school
• Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization
• 1+ year in Utilization Management, Case Management or transferable skills
• Pediatrics and/or NICU experience is a plus
• Must be a Certified Case Manager or eligible to sit for the Certified Case Management Exam within 3 years of starting employment with i360
• Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software

Licenses and Certifications

• Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives