Remote Case Manager, Clinical Review & Care Optimization

Remote Case Manager I position focuses on Enhanced Case Management (ECM) with CMS/vendor coordination and member communication for case evaluation, appropriate referrals, and care plan implementation. Responsibilities include reviewing clinicals and claims, developing and coordinating strategic care plans with vendor partners and Allied Care Clinicians, coordinating with members and clients, obtaining clinical information, managing prescription drug benefits and vendor relationships, documenting outcomes and cost savings, and performing weekly/monthly administrative tasks. Key skills include strong verbal and written communication, interpersonal and customer service abilities, organization, time management, analytical/problem-solving capabilities, knowledge of Medicare/Medicaid and prescription drug benefits, and proficiency with Microsoft Office; a Bachelor’s degree or equivalent experience is required, with 2 years of experience in Group Health Insurance/Self-Funded Health Plans preferred. Remote work environment with standard desk role expectations.