Managed Care Case Manager
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Job Description
Managed Care Case Manager supporting US healthcare authorizations and clinical reviews. Coordinating insurers, facilities, appeals, and EHR records remotely from the Philippines.
Responsibilities:
- Manage pre-admission and prior authorizations with MCOs, Medicare Advantage, and commercial insurers
- Conduct concurrent reviews and clinical chart audits to support continued stays
- Track authorizations, length of stay, and expiration dates to prevent coverage gaps and lost revenue
- Communicate with insurance case managers, medical directors, and facility clinical teams
- Support Peer-to-Peer reviews and appeals when coverage is denied
- Coordinate with intake, nursing, social work, and billing teams
- Maintain accurate authorization records in the EHR
- Provide weekend/high-volume coverage and ensure smooth team handoffs
Requirements:
- 2–4 years of experience as an RN, LPN, USRN, or Healthcare Virtual Assistant with clinical nursing education
- Knowledge of US healthcare insurance, Medicare Advantage, Medicaid MCOs, commercial payors, and InterQual/MCG criteria is a plus
- Experience with PointClickCare, MatrixCare, Availity, NaviHealth, or similar systems
- Strong English communication, organization, attention to detail, and time-management skills
- Ability to manage high-volume authorization workflows independently
- Ability to work full-time during US business hours, including dedicated weekend coverage
- Application and resume must be submitted in English
Benefits:
- Comprehensive Training with extensive initial training and ongoing mentorship
- Clear promotional path with competitive salary increases
- Supportive global team
- Dedicated Team Lead and supervisor
- Remote work from home
- Professional communication with native English speakers to enhance language skills
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