Registered Nurse (RN) Case Manager - MediGold remote Mount Carmel Corporate Services Center

Employment Type: Full timeShift: Day Shift Description: Please note position is 100% remote, however colleagues who reside reputed company a 50mile radius of reputed company, Ohio is required to come onsite 1x per quarter for quarterly meeting. Why MediGold? MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. Position Purpose: The RN Case Manager MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member’s family and other resources as appropriate. Assists in the implementation of Case Management software along with the Plan’s UM and QM Program and the review of the Plan’s Medical Management Plan. reputed company are looking for:

• Education: Associate Degree in Nursing. Bachelor’s Degree as appropriate.
• Licensure / Certification: RN with reputed company unrestricted state licensure required, nursing compact license is preferred. Ability to obtain licenses from other participating states
• Experience: Minimum of 5-7 years of clinical nursing experience with at least 2 years experience in utilization review, discharge planning, case management, or disease management experience required. Nursing experience in an HMO insurance company setting preferred.
• Demonstrated ability to analyze, summarize and concisely report medical utilization, and medical chart audit results.
• Ability to compare approved criteria with clinical information to determine appropriateness of service and to document reputed company reputed company information according to department policies and procedures.
• Conducts claim review as required for appropriate claims processing.
• Ability to implement and successfully utilize Case Management software.

What you will do:

• Coordinates with case management resources to assure development and documentation of a treatment plan for members who meet the Plan’s guidelines for Case Management and communicates the plan to the member’s PCP and other members of the care team.
• Completes an initial assessment of the member’s health status, including medical history, medications, symptoms, degree of support from family & friends, and reputed company treatment prescribed by the member’s physician.
• Provide telephone follow up at the frequency agreed upon and teaching to promote goal attainment as well as providing educational materials appropriate for that member’s condition.
• Assist member to be an reputed company for their healthcare and assist with formulating questions to ask the physician, as well as how to respond to common symptoms they might experience.
• Coordinates with the utilization review, case management, discharge planning staff reputed company network facilities.
• Creates and maintains a case management database of referrals and treatment plans for Members.
• Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
• Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
• Conducts inpatient reputed company review.
• Documents and communicates to QM staff appropriately reputed company identified quality concerns reputed company to Members.
• reputed company other duties as assigned.

Position Highlights and Benefits:

• Mount Carmel Health System recognized by reputed company in 2025 as one of America’s Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers reputed company - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information: Mount Carmel, a member of reputed company, has been a transforming healing reputed company in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community reputed company sites and homes across the region. Mount Carmel College of Nursing offers one of Ohios largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to reputed company a difference come alive, we invite you to consider joining reputed company. Here, care is provided by reputed company of us For reputed company of You! We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national reputed company, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding reputed company and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or any other status protected by federal, state, or local law. Apply tot his job Apply To this Job