Case Manager, RN

in Pittsburgh
, PA
Reference: 19-03585


  • Coordinate the care and services of selected member populations across the continuum of illness
  • Promote effective utilization and monitor healthcare resources
  • Assume a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes
  • Work with the Supervisor/Manager of Case Management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the member

Key Duties and Responsibilities:

  • Interact continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status
  • Assess the options for care including use of benefits and community resources to update the care plan
  • Act as liaison and member advocate between the member/family, physician and facilities/agencies
  • Coordinate community resources with emphasis on medical, behavioral and social services
  • Apply case management standards and maintains HIPAA standards and confidentiality of protected health information
  • Report critical incidents and information regarding quality of care issues
  • Outreach to members telephonically and/or in-person and coordinate member’s case management services
  • In conjunction with the PCP and member, complete a comprehensive assessment and develop a care plan utilizing clinical expertise to evaluate the member’s need for alternative services
  • Assess short-term and long-term needs and establishes case management objectives
  • Request consultation and diagnostic reports from network specialists
  • Perform special projects as assigned

Additional Position Responsibilities:

  • Case load may differ by state and/or location based on contract requirements, membership, plan and/or operational best practice
  • Some states and/or locations may require nurses to occasionally travel to facility or inpatient bedside to conduct assessments or face to face visits


  • A High School diploma or GED (required)
  • A Bachelor’s degree in Nursing or related field (preferred)

Work Experience:

  • 2+ years of experience in a clinical acute care position(s), preferably in home health, physicians office or public health (required)
  • 1+ year of experience in current case management experience (preferred)
  • 2+ years of experience in appropriate experience and qualifications required to assessing members individual needs (preferred)
  • 2+ years of experience in physical health, aging and loss, appropriate support services in the community, frequently used medications and their potential side effects, depression, challenging behaviors, Alzheimer’s disease and other disease related dementias, behavioral health, and issues related to accessing and using durable medical equipment (preferred)

Licenses and Certifications:

  • Licensed Registered Nurse (RN) required
  • Certified Case Manager (CCM) preferred


  • Ability to drive multiple projects a plus
  • Ability to multi-task
  • Ability to work in a fast-paced environment with changing priorities
  • Ability to work independently, handle multiple assignments and prioritize workload
  • Demonstrated time management and priority setting skills
  • Demonstrated interpersonal/verbal communication skills
  • Ability to create, review and interpret treatment plans
  • Demonstrated negotiation skills
  • Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to effectively present information and respond to questions from peers and management
  • Ability to implement process improvements


  • Intermediate knowledge and skills of MS Office including Excel, Word, and Outlook Express
  • Healthcare Management Systems (Generic)

Level of Supervision Received:

  • Plan and arrange own work, refer only unusual cases to supervisors or others