Care Manager, RN

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🔥 48 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Wellcove

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1989

🛡️ Insurance

🏥 Healthcare

☁️ SaaS

Insurance • Healthcare • SaaS

Wellcove is a third‑party administrator (TPA) focused on the senior market and long‑term care (LTC) benefits. Its cloud‑native LTC Now platform and AssuriCare services provide automated claim administration, eligibility determination, auto‑adjudication, payment processing, digital care management, provider matching, risk evaluation/analytics, and business process outsourcing for carriers, state retirement plans, and reinsurers. The company emphasizes automation, payment integrity, and tailored administrative solutions for long‑term care and Medicare supplement administration.

📋 Description

• 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.

🎯 Requirements

• 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.