Peak Care Manager

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Peak Care Manager based in United States.

This role is an opportunity to join a health plan’s medical management team and make a direct impact on the health and well-being of high-risk members.
You will identify members who may benefit from care management and connect them with appropriate clinical, community, and in-network resources.
The position combines clinical judgment, utilization management, quality oversight, and member advocacy.
You will use health assessments, admissions information, outcomes data, and medical records to identify needs and improve care strategies.
The role also contributes to accreditation readiness, delegated program oversight, and continuous quality improvement.
Success requires strong clinical knowledge, attention to detail, sound decision-making, and the ability to collaborate across teams.
This is a full-time remote opportunity for a nurse who wants to help improve both individual outcomes and broader population health.

Accountabilities:

• Participate in the development, implementation, oversight, and delegation of care management programs, helping ensure services effectively address member needs.
• Perform utilization management reviews when required, applying established clinical criteria, guidelines, and organizational policies.
• Manage and triage member self-referrals to appropriate care management programs and services.
• Identify high-risk members using Health Risk Assessment (HRA) information, reporting, admissions data, and other relevant clinical indicators.
• Help members understand their medical benefits and connect them with appropriate in-network providers, community resources, and support programs.
• Identify barriers that may prevent members from achieving optimal health and quality-of-life outcomes and help develop appropriate interventions.
• Analyze member outcomes and HRA data to identify trends, inform program development, and support performance improvement initiatives.
• Audit member records and delegated case management programs using applicable NCQA standards and accreditation requirements.
• Investigate potential quality-of-care concerns and review medical records and other documentation to support safe, high-quality care.
• Participate in case management and quality committees and contribute to the development and continuous improvement of care management processes.
• Assist with reviewing and updating policies, procedures, activities, and resources to align with delegated processes and regulatory requirements.
• Support quarterly reporting, accreditation documentation, and submission of required policies and materials to accrediting organizations.

Requirements:

• Current Registered Nurse (RN) license in the state where services will be provided, or a current multi-state RN license through the enhanced Nurse Licensure Compact (eNLC).
• At least 3 years of healthcare clinical experience .
• A Bachelor’s degree in Nursing is preferred; an Associate of Science in Nursing (ASN) is also acceptable, with candidates currently enrolled in a BSN program expected to complete the degree within three years of hire.
• Experience managing Medicare and/or Medicaid populations is preferred.
• At least 2 years of care management experience is preferred.
• Working knowledge of InterQual and/or Milliman Care Guidelines .
• Knowledge of federal and state requirements, NCQA standards, and industry regulations related to disease management, utilization management, care management, and discharge planning.
• Strong written and verbal communication skills, with the ability to work effectively with members, providers, and internal stakeholders.
• Strong problem-solving and critical-thinking capabilities, particularly when identifying opportunities to improve efficiency, quality, and member satisfaction.
• Excellent attention to detail and the ability to accurately review clinical information, records, and compliance documentation.
• Proficiency with Microsoft Office and standard workplace technology.
• Ability to work independently while collaborating effectively across multidisciplinary teams.

Benefits:

• Remote work: Full-time position designed to be performed remotely within the United States.
• Full-time schedule: 40 hours per week with an exempt employment classification.
• Meaningful clinical impact: Opportunity to improve outcomes for high-risk populations through care coordination, advocacy, and quality-focused interventions.
• Professional development: Exposure to care management, utilization management, quality improvement, accreditation, and population health initiatives.
• Collaborative environment: Work alongside medical management, clinical, quality, and care management professionals.
• Mission-driven work: Contribute to initiatives focused on improving community health, quality of care, and financial outcomes.
• Clinical leadership exposure: Participate in committees, program development, delegated oversight, and accreditation activities.

How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

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We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.