Note: The job is a remote job and is open to candidates in USA. BeVera Solutions, LLC is a rapidly growing public health and professional services company that provides innovative solutions to federal and state agencies. The Case Manager will support member-centered health services through comprehensive care coordination, utilization support, and member advocacy, ensuring timely access to care and compliance with program requirements.

Responsibilities

Provide individualized case management services tailored to each member’s clinical, social, and administrative needs
Coordinate medical monitoring, diagnostic services, and treatment for members receiving care through the Nationwide Provider Network (NPN)
Assist members in navigating the WTCHP care continuum, including understanding benefits, treatment pathways, and required documentation
Support continuity of care by coordinating among NPN providers, the Third-Party Administrator (TPA), Pharmacy Benefits Manager (PBM), and WTCHP Program staff
Deliver both standard and intensive case management services in accordance with WTCHP Case Management and Utilization Management Standard Operating Procedures
Identify barriers to care such as geographic access, provider availability, coordination of benefits, or member adherence, and implement strategies to mitigate those barriers
Promote efficiency and appropriate utilization of services while supporting high member satisfaction and positive health outcomes
Encourage and support member self-management of care over time, as clinically appropriate
Collaborate with NPA utilization management staff to support prior authorization processes related to certified WTC-related conditions
Review clinical documentation and supporting information to ensure services align with Program coverage requirements
Monitor trends in utilization and member needs and communicate emerging issues to leadership to inform program improvements
Serve as an advocate for members by addressing concerns, resolving care coordination issues, and facilitating communication among stakeholders
Assist members in understanding Program policies, rights, responsibilities, and appeals processes
Support outreach efforts to re-engage inactive or hard-to-reach members
Maintain accurate, timely, and compliant case records within the NPA’s secure data and document management systems
Ensure documentation complies with HIPAA, WTCHP privacy requirements, and National Archives and Records Administration (NARA) digitization standards
Participate in bidirectional data exchanges with WTCHP and other Program contractors to ensure consistency and accuracy of member information
Participate in quality assurance activities, audits, and performance monitoring initiatives
Contribute to continuous improvement efforts by identifying trends, systemic issues, and opportunities to enhance member experience and care coordination
Complete required training and maintain up-to-date knowledge of WTCHP policies, procedures, and evolving Program requirements

Skills

Bachelor's degree in Nursing, Social Work, Public Health, Health Administration, or a related field
Minimum of 3–5 years of experience in healthcare case management, care coordination, or utilization management
Active clinical licensure (e.g., RN, LCSW, LMSW, or equivalent) preferred for clinical case management roles
Demonstrated experience working with complex medical populations, chronic conditions, or federally funded health programs
Strong knowledge of healthcare delivery systems, referral networks, and benefits coordination
Experience working with geographically dispersed populations and telephonic or remote case management
Strong interpersonal, communication, and member-engagement skills
Ability to manage complex cases with empathy, professionalism, and attention to detail
Excellent organizational and documentation skills
Proficiency with electronic case management systems and secure data platforms
Ability to work independently while collaborating effectively within a team-based environment
Master's degree
Experience supporting federal health programs or government-funded benefit programs
Familiarity with utilization management, prior authorization processes, and medical necessity determinations
Experience working in multidisciplinary environments involving providers, administrators, and government stakeholders
Cultural competency and experience communicating with diverse populations on sensitive health-related topics

Company Overview

BeVera Solutions provides data science training and consulting. It was founded in 2013, and is headquartered in Atlanta, Georgia, USA, with a workforce of 11-50 employees. Its website is https://www.beverasolutions.com.

BeVera Solutions

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[Remote] Case Manager (WTCHP)