Peak Care Manager

About the Role

This is a full-time remote opportunity for a nurse to join a health plan’s medical management team and make a direct impact on the health and well-being of high-risk members. You will identify members who may benefit from care management and connect them with appropriate clinical, community, and in-network resources. The position combines clinical judgment, utilization management, quality oversight, and member advocacy.

Responsibilities

• Participate in the development, implementation, oversight, and delegation of care management programs to ensure services effectively address member needs.
• Perform utilization management reviews when required, applying established clinical criteria, guidelines, and organizational policies.
• Manage and triage member self-referrals to appropriate care management programs and services.
• Identify high-risk members using Health Risk Assessment (HRA) information, reporting, admissions data, and other relevant clinical indicators.
• Help members understand their medical benefits and connect them with appropriate in-network providers, community resources, and support programs.
• Identify barriers that may prevent members from achieving optimal health and quality-of-life outcomes and help develop appropriate interventions.
• Analyze member outcomes and HRA data to identify trends, inform program development, and support performance improvement initiatives.
• Audit member records and delegated case management programs using applicable NCQA standards and accreditation requirements.
• Investigate potential quality-of-care concerns and review medical records and other documentation to support safe, high-quality care.
• Participate in case management and quality committees and contribute to the development and continuous improvement of care management processes.
• Assist with reviewing and updating policies, procedures, activities, and resources to align with delegated processes and regulatory requirements.
• Support quarterly reporting, accreditation documentation, and submission of required policies and materials to accrediting organizations.

Requirements

• Current Registered Nurse (RN) license in the state where services will be provided, or a current multi-state RN license through the enhanced Nurse Licensure Compact (eNLC).
• At least 3 years of healthcare clinical experience.
• A Bachelor’s degree in Nursing is preferred; an Associate of Science in Nursing (ASN) is also acceptable, with candidates currently enrolled in a BSN program expected to complete the degree within three years of hire.
• Experience managing Medicare and/or Medicaid populations is preferred.
• At least 2 years of care management experience is preferred.
• Working knowledge of InterQual and/or Milliman Care Guidelines.
• Knowledge of federal and state requirements, NCQA standards, and industry regulations related to disease management, utilization management, care management, and discharge planning.
• Strong written and verbal communication skills, with the ability to work effectively with members, providers, and internal stakeholders.
• Strong problem-solving and critical-thinking capabilities, particularly when identifying opportunities to improve efficiency, quality, and member satisfaction.
• Excellent attention to detail and the ability to accurately review clinical information, records, and compliance documentation.
• Proficiency with Microsoft Office and standard workplace technology.
• Ability to work independently while collaborating effectively across multidisciplinary teams.

Benefits

• Remote work: Full-time position designed to be performed remotely within the United States.
• Full-time schedule: 40 hours per week with an exempt employment classification.
• Meaningful clinical impact: Opportunity to improve outcomes for high-risk populations through care coordination, advocacy, and quality-focused interventions.
• Professional development: Exposure to care management, utilization management, quality improvement, accreditation, and population health initiatives.
• Collaborative environment: Work alongside medical management, clinical, quality, and care management professionals.
• Mission-driven work: Contribute to initiatives focused on improving community health, quality of care, and financial outcomes.
• Clinical leadership exposure: Participate in committees, program development, delegated oversight, and accreditation activities.