Medical Case Manager

Industry: Finance & Insurance


5 - 7 years

Posted 33 days ago

Job Duties & Responsibilities

The case manager will perform the six essential activities of case management.

  • Assessment – The case manager will collect in-depth information about a person's situation and functioning to identify individual needs in order to identify members at risk for high cost medical care and develop a comprehensive case management plan that will address those needs.
  • Planning – The case manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific.
  • Implementation – The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan.
  • Coordination – The case manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the case management plan.
  • Monitoring – The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan.
  • Evaluation – At appropriate and repeated intervals, the case manager will determine the plan's effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts.

Case Management Functions

  • Conduct a thorough and objective evaluation of the client's current status including physical, psychosocial, environmental, financial, and health status expectation.
  • As a client advocate, seek authorization for case management from the recipient of services (or designee).
  • Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short- and long-term).
  • Identify opportunities for intervention.
  • Set goals and time frames for goals appropriate to individual.
  • Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
  • Maintain communication and collaborate with patient, family, physicians and health team members, and payer representatives.
  • Compare the client's disease course to established pathways to determine variances and then intervene as indicated.
  • Routinely assess client's status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
  • Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
  • Report quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals.
  • Participate in Inter-reviewer Reliability to identify quality of care issues and criteria inconsistencies.
  • Maintain requirements of documentation and caseload as reflected in audits to meet compliance with quality standards.
  • Conduct case screenings using applicable tools to determine appropriate levels needed to meet member needs.

Job Qualifications


  • Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
  • Must have or be able to be licensed in multiple states if required


  • Minimum of five (5) years health care experience with at least three (3) years of clinical experience,
  • Prefer two (2) years experience in Utilization Management, Case Management or Managed Care.


  • Certified Case Manager (CCM®) credential preferred; required to take examination when eligible. Case Managers must obtain a CCM certification within 2 years of hire as a case manager or they will no longer be able to perform case management functions
  • Excellent oral and written communication skills, with problem-solving abilities.
  • Basic PC computer skills required with emphasis on Microsoft Office applications preferred
  • Various immunizations and/or associated medical tests may be required for this position.

Job Specific Requirements:

Preference will be given to candidates in Wayne, Giles, Lincoln, Putnam, Fentress, Overton and Clay countiesNumber of Openings Available:

1Worker Type: