Top 5860 Utilization Manager Rn Jobs

Claims - Care Manager, RN, Claims
Wellcove —Remote
- Full-time
- Remote
- RN License
- Mid-level
- Geriatrics
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2d
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Program Manager - Cardiac Rehabilitation
SouthEast Alaska Regional Health Consortium —Juneau, AK
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RN Case Manager - Day Shift - Sign-on Bonus
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Nurse Manager - Telemetry
MountainView Regional Medical Center —Las Cruces, NM
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Nurse Educator (RN)
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Monogram Health Professional Services —Georgia
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MTF Biologics —Syracuse, NY
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Nurse Manager, Behavioral Health Services
Signet Health Corporation —Greensboro, NC
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Adaptive Home Health —Detroit, MI
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Hospice Clinical Manager
All Care —Lynn, MA
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2d
Service Line Manager (RN) Ambulatory Surgery Center Full Time Day
Jersey City Medical Center —Jersey City, NJ
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- Full-time
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- 5 years
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Claims - Care Manager, RN, Claims

Wellcove
Remote

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Job Details

Full-time

Qualifications

RN License

Full Job Description

Who We Are
Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.

Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

We are seeking an experienced Registered Nurse (RN) to serve as a Care Manager supporting Long Term Care (LTC) insurance claims. This individual contributor role is responsible for conducting comprehensive clinical eligibility reviews to determine whether policyholders meet the benefit eligibility requirements outlined in their LTC policy.
The Care Manager, RN will complete and document Chronically Ill Certifications (CICs) and develop Plans of Care (POCs) for initial claims and ongoing recertifications, ensuring determinations are clinically sound, and policy aligned.

Key Responsibilities

Perform detailed clinical reviews of LTC claim files to determine eligibility in accordance with policy provisions and regulatory requirements.
Assess Activities of Daily Living (ADLs), cognitive impairment, diagnoses, comorbidities, and level of care needs.
Review medical records, Minimum Data Set (MDS) assessments, facility documentation, home health records, daily visit notes, and supporting claim forms.
Determine whether the insured meets the policy definition of Chronically Ill.
Prepare and document Chronically Ill Certifications (CICs) and individualized Plans of Care (POCs) for initial approvals and recertifications.
Clearly document clinical rationale to support benefit determinations.
Collaborate with Claims, Eligibility, and Customer Service teams to obtain additional documentation when necessary.
Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

Qualifications

Active, unrestricted Registered Nurse (RN) license required.
Clinical experience in long-term care, home health, geriatrics, case management, or utilization review preferred.
Experience reviewing medical records and assessing functional and cognitive impairment.
Knowledge of LTC insurance benefit triggers, ADL requirements, and chronically ill certification standards preferred.
Strong clinical judgment, critical thinking, and documentation skills.
Ability to manage multiple cases and meet turnaround expectations.

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.

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Refine Your Search

Utilization Manager Rn jobs

Claims - Care Manager, RN, Claims

Utilization Review Manager - PRN

Denials & Appeals Administrator (RN)

Market Physician Executive (MPE) - Atlanta, GA

UM Case Manager/Appeals Coordinator

Program Manager - Cardiac Rehabilitation

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Nurse Educator (RN)

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Market Physician Executive (MPE) - Float

Manager Behavioral Health

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RN Unit Manager

Nurse Manager, Behavioral Health Services

Branch Clinical Manager (RN) Home Health

Market Physician Executive (MPE)

Market Physician Executive (MPE)

Hospice Clinical Manager

Service Line Manager (RN) Ambulatory Surgery Center Full Time Day

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