Are you a licensed healthcare professional skilled at bridging the gap between patient care, clinical necessity, and payor navigation? As an Internal Case Manager, you will play a central role in driving quality, cost-effective patient outcomes. You will lead the collaborative process of assessment, utilization management, advocacy, and discharge planning—ensuring every patient receives the care they need while protecting against financial risks and unreimbursed claims.

Position HighlightsUtilization & Concurrent Review: Verify, document, and submit complete clinical data to payors from pre-admission through concurrent review (using PointClickCare and NetHealth) to justify medical necessity.

Payor Negotiations & Authorizations: Negotiate level of care (LOC), length of stay (LOS), daily rates, and service extensions. Secure approvals for procedures, treatments, equipment, and non-formulary medications.

Interdisciplinary Collaboration: Serve as the clinical reimbursement resource for physicians, nurse practitioners, social workers, MDS coordinators, and rehab directors to align care plans with contract terms.

Financial Risk & Appeals Management: Monitor cases for service over/under-utilization to prevent claim denials. Assist with clinical appeals and ensure timely delivery of Notices of Non-Coverage.

Discharge & Transition Planning: Identify risk factors, chronicity, and barriers to discharge early. Partner with network providers and local staff to ensure safe, seamless patient transitions.

*Must be a graduate of an approved school of nursing with a license as a Registered Nurse or equivalent professional license (Physical Therapist, Occupational Therapist, Speech Therapist, Licensed Social Worker or Master of Social Work). 

*Bachelor’s degree in nursing preferred. Certified Case Management (CCM) or related clinical certifications are also preferred.

*Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required.

*Prior experience using evidence-based clinical decision support criteria (e.g.Interqual, Milliman)

*Advanced knowledge of third-party reimbursement, insurance coverage and contract requirements.

*Experience in rehabilitation nursing, acute care and/or the insurance field is preferred. 

*Two years’ full-time experience in case management, which includes service to short/long-term facility-based residents, is preferred.

*Tuition, Travel, Wireless Service, and Other Discounts

*Employee Assistance Program to support mental health

*Employee Foundation to financially assist through unforeseen hardships

*Health, Dental, Vision, Company-paid life insurance, 401K, Paid Time Off

*Free 24/7 virtual health care provided by licensed doctors for all Anthem medically enrolled employees and their immediate family members

*On-Demand Pay Program that allows for instant access to a portion of the money you’ve already earned 

We also offer several voluntary insurances such as:*Pet Insurance*Term and Whole Life Insurance*Short-term Disability*Hospital Indemnity*Personal Accident*Critical Illness*Cancer Coverage

Restrictions apply based on collective bargaining agreements, applicable state law and factors such as pay classification, job grade, location, and length of service.