Care Management Nurse - Philippines - ICAN BPO Pvt. Ltd.

    ICAN BPO Pvt. Ltd.
    ICAN BPO Pvt. Ltd. Philippines

    21 oras ang nakalipas

    Upper Management / Consulting
    Paglalarawan

    Job Title

    Care Management Nurse (USRN) – Medicare Advantage

    Location

    India / Philippines (Onsite and/or Remote)

    Reporting To

    Care Management Lead / Clinical Operations Manager

    Role Overview

    The Care Management Nurse (USRN) – Medicare Advantage is responsible for delivering comprehensive telephonic and/or platform-based care management services to Medicare Advantage members across the continuum of care.

    This role focuses on clinical assessment, care planning, risk stratification, member education, chronic condition management, transitional care, and coordination with providers to improve quality outcomes, close care gaps, and reduce avoidable utilization.

    The position requires an active USRN license, strong clinical judgment, knowledge of CMS and Medicare Advantage guidelines, and experience managing elderly and complex populations.

    This is a quality-driven, outcomes-focused role supporting CMS Star Ratings, HEDIS measures, risk adjustment initiatives, and utilization management programs.

    Key Responsibilities

    Comprehensive Clinical Assessment

    • Conduct telephonic health risk assessments (HRAs) for Medicare Advantage members
    • Perform post-discharge and transitional care management outreach
    • Assess chronic conditions such as CHF, COPD, Diabetes, CAD, CKD, and Behavioral Health conditions
    • Evaluate medication adherence, functional status, social determinants of health (SDOH), and psychosocial barriers

    Care Planning & Coordination

    • Develop individualized, evidence-based care plans
    • Establish measurable goals in collaboration with members and caregivers
    • Coordinate with PCPs, specialists, SNFs, home health, and ancillary providers
    • Facilitate referrals for disease management, behavioral health, and community resources

    Risk Stratification & Escalation

    • Stratify members based on clinical acuity and utilization patterns
    • Identify high-risk members requiring intensive case management
    • Escalate complex cases per defined Medicare Advantage protocols
    • Support readmission prevention initiatives

    CMS & Quality Program Support

    • Support CMS Star Ratings initiatives
    • Close care gaps aligned to HEDIS and preventive health measures
    • Ensure documentation supports Risk Adjustment (HCC) accuracy
    • Maintain compliance with Medicare Advantage regulatory guidelines

    Utilization & Clinical Review (as applicable)

    • Participate in medical necessity reviews per payer guidelines
    • Review inpatient, outpatient, and post-acute services
    • Support prior authorization or concurrent review workflows when required

    Documentation & Compliance

    • Maintain accurate, audit-ready documentation in care management platforms
    • Adhere strictly to HIPAA and US healthcare data privacy regulations
    • Meet defined KPIs including quality scores, productivity, outreach targets, and adherence
    • Support internal and external CMS audit readiness

    Member Engagement

    • Educate members on disease management and preventive care
    • Promote medication compliance and lifestyle modifications
    • Provide culturally sensitive, empathetic engagement for elderly populations
    • Address barriers to care including transportation, cost, literacy, or caregiver support

    Required Qualifications

    Mandatory

    • Active and unrestricted USRN License
    • 3–7+ years of clinical nursing experience
    • 2+ years in Medicare Advantage, Managed Care, or Population Health programs
    • Strong understanding of CMS, Star Ratings, HEDIS, and Risk Adjustment
    • Experience in telephonic care management
    • Proficiency in care management platforms and EMR systems
    • Excellent verbal and written English communication skills

    Preferred

    • CCM (Certified Case Manager) certification
    • Experience in Transitional Care Management (TCM)
    • Experience in Utilization Management (UM)
    • Prior experience in healthcare BPO supporting US payers
    • Knowledge of InterQual or MCG guidelines

    Key Competencies

    • Strong clinical judgment and critical thinking
    • Ability to manage complex geriatric populations
    • Risk stratification and care gap closure expertise
    • Knowledge of Medicare Advantage compliance frameworks
    • Empathy and member-centric approach
    • Documentation accuracy and audit discipline
    • Time management and SLA adherence

    Work Expectations

    • Flexible to work in US shifts
    • Comfortable in structured KPI-driven environments
    • Ability to manage high member outreach volumes
    • Mandatory completion of HIPAA and CMS compliance training
    • Willingness to cross-train across care management programs

    Career Path

    • Senior Care Manager – USRN
    • Clinical Quality Auditor
    • Care Management Team Lead
    • Clinical Operations Manager – Medicare Programs
    • Population Health Program Lead
  • Trabaho sa kumpanya

    Manager, Case Management Nurse

    Para lamang sa mga rehistradong miyembro

    · The Case Management Nurse Manager is responsible for overseeing the daily operations of the Case Management department and leading a team of Case Management Nurses. This role involves ensuring efficient care coordination, managing healthcare costs, and maintaining high-quality ...

    Manila, National Capital Region Philippines $100,000 - $145,000 (USD) bawat taon

    1 linggo ang nakalipas

  • Trabaho sa kumpanya

    Nurse Shift Manager

    Para lamang sa mga rehistradong miyembro

    Nurse Shift Manager oversees all nursing activities during assigned shift ensuring compliance with hospital standards and promotes safe quality health care.Ensures administrative clinical supports are provided to nurses after office hours weekends and holidays. · ...

    Manila

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    Licensed Care Management Nurse/Doctor

    Para lamang sa mga rehistradong miyembro

    We are seeking a Licensed Medical Nurse/Caregiver Virtual Assistant to support a U.S.-based clinical care management team. · This role is ideal for a healthcare professional who is experienced in patient coordination and documentation,and who can confidently support clinical oper ...

    Manila

    3 linggo ang nakalipas

  • Trabaho sa kumpanya Remote na trabaho

    Nursing Recruiter (Healthcare Relations Manager) - A232

    Para lamang sa mga rehistradong miyembro

    The Nursing Recruiter (Healthcare Relations Manager) plays a central role in guiding nurses through the recruitment journey—from initial screening through offer and onboarding coordination. · Own the end-to-end nurse candidate journey from initial screening through offer stage. · ...

    Manila, National Capital Region

    2 linggo ang nakalipas

  • Trabaho sa kumpanya

    Junior Assistant Medical Manager – 'Safety Nurse'

    Para lamang sa mga rehistradong miyembro

    Fortrean Safety Nurses provide medical safety expertise to sponsors of drugs/devices/combo products in post-marketing period. · Assess pharmacovigilance cases for patient safety · ...

    Manila, National Capital Region

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    Utilization Review Nurse Manager

    Para lamang sa mga rehistradong miyembro

    NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now. · We are currently seeking a Utilization Review Nurse Manager (USRN) to join ou ...

    Manila

    8 oras ang nakalipas

  • Trabaho sa kumpanya

    Junior Assistant Medical Manager – 'Safety Nurse'

    Para lamang sa mga rehistradong miyembro

    Job Overview: · Fortrean Safety Nurses provide medical safety expertise, directly and indirectly, to sponsors of drugs, devices, and combination products, in the post marketing period of the drug development process. Working as part of a team you will be utilizing your medical kn ...

    Manila

    2 araw ang nakalipas

  • Trabaho sa kumpanya

    Chief Nursing Manager

    Para lamang sa mga rehistradong miyembro

    We are seeking a Chief Nursing Manager with active PHRN license, at least 5 years of clinical nursing experience as a Chief Nurse/Nursing Manager, good English communication skills, proven track record in outpatient clinical governance, nursing protocol development, and staff sup ...

    Makati

    2 linggo ang nakalipas

  • Trabaho sa kumpanya

    Nursing Recruiter (Healthcare Relations Manager) - A232

    Para lamang sa mga rehistradong miyembro

    We're seeking an experienced Nursing Recruiter (Healthcare Relations Manager) to guide nurses through the recruitment journey from initial screening through offer and onboarding coordination. · Candidate Relationship Management: Own the end-to-end nurse candidate journey from ini ...

    Manila

    2 linggo ang nakalipas

  • Trabaho sa kumpanya

    Licensed Care Management Nurse Doctor Caregiver

    Para lamang sa mga rehistradong miyembro

    We are seeking a Licensed Medical Nurse/Caregiver Virtual Assistant to support a U.S.-based clinical care management team. · This role is ideal for a healthcare professional who is experienced in patient coordination, documentation, and compliance, and who can confidently support ...

    Manila

    3 linggo ang nakalipas

  • Trabaho sa kumpanya

    Clinic Management Nurse

    Para lamang sa mga rehistradong miyembro

    Clinic Management Nurse position at Panoptik Global in Makati on a 6-month contract with possible extension. · Provide primary & emergency care (consultations, medication dispensing) · ...

    Makati

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    Case Manager Nurse

    Para lamang sa mga rehistradong miyembro

    TASQ is seeking a USRN case manager to join their team. · Engage regularly with clinical specialties and physicians. · Communicate with insurance providers, patients, families, legal representatives, and staff from other medical facilities. · ...

    Pasig, Metro Manila, Philippines

    2 linggo ang nakalipas

  • Trabaho sa kumpanya

    Assistant Manager-Healthcare Operations Management-Case Management Nursing

    Para lamang sa mga rehistradong miyembro

    The primary responsibility of this role is to oversee the day-to-day operations of a team of nurses who assist their onshore counterparts with administrative case management tasks. To monitor performance according to established standards and conducts performance evaluations. The ...

    Pasay Buong oras

    2 araw ang nakalipas

  • Trabaho sa kumpanya

    Licensed Care Management Nurse Medical VA Caregiver

    Para lamang sa mga rehistradong miyembro

    We are seeking a Licensed Medical Nurse/Caregiver Virtual Assistant to support a U.S.-based clinical care management team. · This role is ideal for a healthcare professional who is experienced in patient coordination, documentation and compliance. · ...

    Manila

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    USRN Case Manager Nurse

    Para lamang sa mga rehistradong miyembro

    The Case Manager Nurse will regularly liaise with multiple clinical specialties and doctors. · This role also involves consistent interactions with insurance providers, · patients and their families, · legal delegates, · and representatives from other medical care institutions. · ...

    Ortigas, Metro Manila

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    Healthcare Denials Management Nurse

    Para lamang sa mga rehistradong miyembro

    We are seeking a Registered Nurse to join our dynamic and growing team. · ...

    Pasay, Metro Manila

    1 buwan ang nakalipas

  • Trabaho sa kumpanya

    Chief Nursing Services Manager

    Para lamang sa mga rehistradong miyembro

    About the job: Chief Nursing Services Manager | Makati | Dayshift · JOB DESCRIPTION · Leadership and Oversight of Nursing OperationsProvides centralized leadership and direction to nurse supervisors and the nursing workforce deployed across all care clinics. · Implements organiza ...

    Makati City

    5 araw ang nakalipas

  • Trabaho sa kumpanya

    Chief Nursing Services Manager

    Para lamang sa mga rehistradong miyembro

    JOB SPECIFICATIONS/QUALIFICATIONS: · Bachelor's degree in Nursing; Licensed and Registered Nurse in the Philippines · Master's degree in nursing, Healthcare Administration, or equivalent is preferred · At least 5 years of clinical nursing experience with a minimum of 5 years in a ...

    Makati City

    4 araw ang nakalipas

  • Trabaho sa kumpanya

    Chief Nursing Services Manager

    Para lamang sa mga rehistradong miyembro

    · About the job: Chief Nursing Services Manager | Makati | Dayshift · JOB DESCRIPTION · Leadership and Oversight of Nursing OperationsProvides centralized leadership and direction to nurse supervisors and the nursing workforce deployed across all care clinics. · Implements organ ...

    Makati City, Metro Manila, Philippines

    1 araw ang nakalipas

  • Trabaho sa kumpanya

    Chief Nursing Services Manager

    Para lamang sa mga rehistradong miyembro

    · Work Setup: Onsite (MAKATI HEAD OFFICE) · Schedule: DAYSHIFT · JOB DESCRIPTION · Leadership and Oversight of Nursing OperationsProvides centralized leadership and direction to Nurse Supervisors and the nursing workforce deployed across all care clinics. · Implements organizati ...

    Makati City, Metro Manila, Philippines

    9 oras ang nakalipas

Trabaho
>
Manila