Remote Case Manager

Job Title: Remote Case Manager

Job ID: 21517-1
Location: Pittsburgh, PA (Remote – must reside in Pennsylvania; candidates anywhere in PA are eligible, with preference for Pittsburgh-area candidates)
Contract Duration: 6 Months
Position Type: Contract
Start Date: ASAP
Eligibility: US Citizens only

Sigma Systems Inc is currently seeking a Remote Case Manager to join our client's team at Wholecare. This is an excellent opportunity for a licensed Registered Nurse with strong Disease Management and clinical assessment experience who is passionate about care coordination, member education, and helping individuals with complex health needs improve their ability to self-manage and navigate the healthcare system. The ideal candidate will have prior case management experience, strong telephonic outreach skills, and experience working with Medicaid or managed care populations.

Job Overview

The Case Manager will function as a primary clinician for members with complex health needs, providing services ranging from basic health coaching to intensive case management. The role focuses heavily on Disease Management, clinical assessments, care coordination, member education, and behavior change. The Case Manager will conduct telephonic assessments, develop individualized care plans, coordinate with providers and community resources, and maintain ongoing communication with members to support their health goals.

Key Responsibilities

• Primary Clinician: Manage members with complex health needs across the continuum of case management services, from basic coaching to intensive intervention.
• Clinical Assessments: Conduct telephonic clinical assessments addressing members' health and wellness needs using strong clinical assessment and motivational interviewing skills.
• Disease Management: Support members with chronic and complex conditions by providing education, coaching, resources, and interventions that promote self-management and positive behavior change.
• Care Planning: Develop case-specific or condition-specific plans of care using the clinical information system, establishing short- and long-term health goals.
• Ongoing Member Contact: Establish and maintain regular telephonic contact with members to review progress, reassess needs, and modify care plans when appropriate.
• Care Coordination: Communicate with treating providers in complex clinical situations requiring case management intervention.
• Clinical Consultation: Serve as a subject matter expert to other clinical teams by providing education, consultation, and training when needed.
• Resource Coordination: Identify online, telephonic, and community-based resources and assist members in accessing services that support their health goals.
• Member Education: Educate members regarding health conditions, self-management strategies, preventive care, lifestyle improvements, and available healthcare resources.
• Prevention & Wellness: Proactively incorporate preventive health services and lifestyle improvement opportunities into member interactions and coaching.
• Documentation & Compliance: Ensure all activities are accurately documented and performed in accordance with business processes, regulatory requirements, and accreditation standards.
• Benefits & Service Coordination: Assist with coordination of services, including appeals/denials, provider inquiries, claims processing, and interpretation of benefit information when necessary.
• Additional Duties: Perform other duties as assigned, including coordination related to specialized services such as transplant facilities and other member support programs.

Qualifications & Requirements

Education & Licensing:

• Must be a current, active Registered Nurse (RN) license in the state of Pennsylvania.
• Certified Case Manager (CCM) certification preferred.
• Must reside in Pennsylvania to work remotely.
• US Citizenship required.

Experience:

• 5+ years of relevant healthcare/case management experience.
• Disease Management experience is required.
• Strong clinical assessment experience, particularly for care coordination and member education.
• Prior Case Management experience.
• Experience working in Managed Care environments.
• Experience working with the Medicaid population strongly preferred.
• Telephonic Case Management / telephonic outreach experience preferred.
• Experience developing and managing individualized care plans.
• Experience identifying and coordinating community resources.
• Knowledge of preventive health services and chronic disease management.
• Experience with an 1-800/member service line preferred.

Skills & Abilities:

• Strong clinical assessment and care coordination skills.
• Excellent verbal and written communication skills.
• Strong member education and motivational interviewing abilities.
• Ability to work independently and effectively manage time and caseloads.
• Strong organizational and documentation skills.
• Compassionate and professional approach when working with members.
• Strong understanding of chronic disease management and health promotion.
• Excellent work ethic and ability to operate effectively in a remote environment.

Additional Requirements

• Candidates must complete the Care Manager Assessment.
• Disease Management experience is a key requirement for this position. The manager is specifically seeking nurses with strong clinical assessment skills who can perform care coordination and educate members as part of the Disease Management program.
• Prior Case Management, telephonic experience, Medicaid knowledge, and CCM certification are strong advantages.