RN Case Manager at Rezilient Health

Raleigh, North Carolina, United States -

Full Time

Start Date

Immediate

Expiry Date

30 Dec, 25

Salary

0.0

Posted On

01 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Care Coordination, Patient Advocacy, Insurance Benefits, Prior Authorizations, Referral Management, Organizational Skills, Problem-Solving, Communication Skills, EHR Systems, Payer Portals, Medical Records, Healthcare Technology, Patient Care, Documentation, Collaboration, Training

Industry

Hospitals and Health Care

Description

As a Care Manager at Rezilient Health, you will play a critical role in supporting patients, providers, and partners throughout the care continuum. You will lead the clinical onboarding of new contracts, manage complex tasks, coordinate referrals and authorizations, and ensure seamless communication between all stakeholders. Your work will directly impact patient outcomes, operational efficiency, and the overall success of our innovative Cloud Clinic model. At Rezilient, we’re dedicated to revolutionizing primary and specialty care by delivering convenient, timely, and seamless access to healthcare. Our innovative hybrid CloudClinic model, powered by our onsite team of Medics and virtual Providers fosters a personalized and digital healthcare experience, putting the patient at the center of their care. By leveraging cutting-edge technology, we streamline care delivery, allowing our Providers to focus on patient well-being, and we continuously expand our specialty services to provide the most comprehensive and convenient healthcare possible. Care Navigation & Patient Advocacy Coordinate and manage patient referrals, including high-priority cases, ensuring timely follow-up and resolution of health concerns. Serve as a patient advocate by facilitating communication between patients, families, providers, and payers to optimize health benefits. Communicate proactively with patients to provide updates, answer questions, and accommodate preferences related to referrals, orders, and care navigation. Identify and address barriers to care (e.g., transportation, financial, language, or health literacy challenges) and proactively support development of solutions to ensure patients receive timely, appropriate services. Maintain organized, accurate, and detailed records of all care coordination activities in accordance with HIPAA and all applicable privacy regulations. Care Coordination & Prior Authorizations Lead and manage prior authorization processes end-to-end, including peer-to-peer reviews, insurance rebuttal letters, single case agreements, and coordination with plan representatives. Facilitate the retrieval and secure transfer of medical records from previous specialists, manage release of information forms, and ensure all necessary documentation is available for patient care. Conduct comprehensive insurance benefit reviews for employer plans, documenting coverage for preventative services, behavioral health, specialty care, and pharmacy needs. Monitor and track the status of authorizations, referrals, and orders to ensure timely completion. Navigate provider orders based on patient health plans and insurance networks on behalf of patients. Stakeholder & Partner Collaboration Serve as the liaison with point solutions and cost containment partners, ensuring training, logins, and functionality are established. Collaborate with clinical teams, providers, and external partners to coordinate patient referrals, orders, and procedures in accordance with medical plan benefits and evidence-based guidelines. Communicate with insurance administrators and healthcare facilities to verify provider participation, coverage, pre-authorization requirements, and scheduling availability. Build and maintain strong working relationships with internal and external partners to facilitate seamless care transitions. Process Improvement & Training Provide input to care coordination workflows, training materials, and standard operating procedures. Assist in building and maintaining databases of preferred specialty providers for all contracts, ensuring up-to-date and accurate information. Qualifications Required: Nursing degree or paramedic licensure (or equivalent experience) Minimum 3 years of experience in care coordination, care and/or case management Strong knowledge of insurance benefits, prior authorizations, and referral management Excellent organizational, problem-solving, and communication skills Demonstrated ability to manage multiple priorities in a fast-paced, evolving environment Proficiency with EHR systems, payer portals, and standard office software Preferred: Certified Case Manager (CCM) certification Experience in a startup or high-growth healthcare technology environment Prior experience as a Medical assistant and/or Billing and Coding This opportunity offers the chance to shape the future of healthcare in a culture where your ideas and contributions have a meaningful impact on the organization's future. You’ll be part of a supportive, collaborative, and diverse team, with competitive compensation and benefits that include generous PTO, paid family leave, comprehensive medical, dental, vision, and life insurance, as well as stock options.

Responsibilities

As an RN Case Manager, you will coordinate patient referrals and manage prior authorization processes while ensuring effective communication among all stakeholders. Your role is crucial in enhancing patient outcomes and operational efficiency within the care continuum.