Registered Nurse (RN) Case Manager - MediGold remote

Employment Type:Full timeShift:Day ShiftDescription:Please note position is 100% remote, however colleagues who reside within a 50mile radius of Columbus, Ohio is required to come onsite 1x per quarter for quarterly meeting.Why MediGold? MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.Position Purpose:The RN Case Manager MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member’s family and other resources as appropriate.Assists in the implementationofCaseManagementsoftwarealongwiththePlan’sUMandQMProgram and the review of the Plan’s Medical Management Plan.What we are looking for:• Education: Associate Degree in Nursing. Bachelor’s Degree asappropriate. • Licensure / Certification: RN with current unrestricted state licensurerequired, nursing compact license is preferred. Ability to obtain licenses from other participating states• Experience: Minimum of 5-7 yearsof clinical nursing experience with at least 2 years experience in utilization review, discharge planning, case management, or disease management experience required. Nursing experience in an HMO insurance company setting preferred.• Demonstrated ability to analyze, summarize and concisely report medical utilization, and medical chart audit results. • Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies andprocedures. • Conducts claim review as required for appropriate claimsprocessing. • Ability to implement and successfully utilize Case Managementsoftware. What you will do:• Coordinates with case management resources to assure development and documentation of a treatment plan for members who meet the Plan’s guidelines for Case Management and communicates the plan to the member’s PCP and other members of the care team.• Completes an initial assessment of the member’s health status, including medical history, medications, symptoms, degree of support from family& friends, and current treatment prescribed by the member’s physician. • Provide telephone follow up at the frequency agreed upon and teaching to promote goal attainment as well as providing educational materials appropriate for that member’scondition. • Assist member to be an advocate for their healthcare and assist with formulating questions to ask the physician, as well as how to respond to common symptoms they mightexperience.• Coordinates with the utilization review, case management, discharge planning staff within network facilities. • Creates and maintains a case management database of referrals and treatment plans forMembers. • Coordinates with Medical Director/Associate Medical Directors on case-specificissues. • Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues. • Conducts inpatient concurrentreview. • Documents and communicates to QM staff appropriately all identified quality concerns related to Members.• All other duties asassigned. Position Highlights andBenefits:• Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers. • Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one. • Retirement savings account with employer match starting on day one. • Generous paid time off programs. • Employee recognition programs. • Tuition/professional development reimbursement starting on day one. • RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.• Relocation assistance (geographic and position restrictions apply). • Employee Referral Rewards program. • Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day! • Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups. Ministry/Facility Information:Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years.Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team.Here, care is provided by all of us For All of You! We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Our CommitmentRooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings.By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law. Apply tot his job